Title: QUILT SEMINAR AN APPRAISAL OF COMMUNICATION TEACHING AT POSTGRADUATE LEVEL ACROSS HEALTHCARE CURRICU
1QUILT SEMINARAN APPRAISAL OF COMMUNICATION
TEACHING AT POSTGRADUATE LEVEL ACROSS
HEALTHCARE CURRICULA SRIKANT SARANGI
Cardiff University
Cardiff University, 10 March 2008
2OUTLINE
- Introduction Health Communication Research
Centre (HCRC) and its Remit - Patient-centredness and the communicative turn in
healthcare delivery - Rethinking communication going beyond skills
approach - Background to the Project fact finding (mild)
intervention in a consultative paradigm - An overview of work in progress (Phases 1 2)
- Future agenda?
3HEALTH COMMUNICATION RESEARCH CENTRE
-
- The Health Communication Research Centre (HCRC)
was established in 1997-98 as an
interdisciplinary initiative, with a focus on
Research and Research-led teaching/training in
healthcare (i) the interactional domain (ii)
the public domain. - www.cardiff.ac.uk/encap/hcrc
- healthcom_at_cardiff.ac.uk
4RESEARCH PROJECTS AN OVERVIEW
- Genetic Counselling Genetic Testing
- Genetic explanations, health and identity
- Palliative Care
- Primary Care Antibiotics prescription
- NHS DIRECT WALES (websites and telephone triage)
- HIV/AIDS and Quality of Life
- Obesity in the media
- Illness narratives chronic fatigue syndrome
young people with IBD, Type 1 Diabetes - Professional examinations (OSCE, RCGP)
- Problem-Based Learning in medical curriculum
- Wales Asylum Seeking and Refugee Doctors (WARD)
programme
5HIGHLIGHTS OF HCRC ACTIVITIES
- Annual Conference on Communication, Medicine and
Ethics (COMET) since 2003 - The Cardiff Lecture Series since 2000 (accessible
via website www.cardiff.ac.uk/encap/hcrc - Annual interdisciplinary workshops
- Annual Summer Schools
- Regular Health and Discourse Seminars (HEADS)
- Teaching/supervision input to medical and
healthcare curricula - Pilot projects in neglected areas of healthcare
communication. - Founding Journal Communication Medicine
6- CONTRIBUTORS TO FIRST ISSUE
- Atkinson, P. (Cardiff University)
- Barrett, R. J. (University of Adelaide)
- Cicourel, A. V. (University of California, San
Diego) - Frankel, R. M. and Hourigan, N. (Indiana
University School of Medicine) - Hamilton, H. E. (Georgetown University)
- Hydén, L. and Baggens, C. (Linköping University)
- Iedema, R., Sorensen, R., Braithwaite, J. and
Turnbull, E. (University of New South Wales) - Körner, H., Hendry, O., and Kippax, S.
- Li, H.Z., Krysko, M., Desroches, N.G. and Deagle,
G. (University of Northern British Columbia) - Roberts, C. (Kings College London), Sarangi, S.
(Cardiff University) and Moss, B. (Kings College
London) - DISCUSSION FORUM - Mishler, E. G. (Harvard
Medical School)
7- COMET
- CHRONOLOGY
- 2003 Cardiff
- 2004 Linköping, Sweden
- 2005 Sydney, Australia
- 2006 Cardiff
- 2007 Lugano, Switzerland
- 2008 Cape Town, S Africa
- 2009 Cardiff
- 2010 Boston, USA
- 2111 Nottingham, UK
- 2112 Gent, Belgium
Return
8Return
9 - PATIENT-CENTREDNESS
- THE COMMUNICATIVE TURN IN HEALTHCARE DELIVERY
10PATIENT-CENTREDNESS IN HEALTHCARE DELIVERY
- EVIDENCE-BASED MEDICINE (the dominant biomedical
paradigm) - NARRATIVE-BASED MEDICINE (cf. ethnomedical
perspective (Faberga 1975 biopsychosocial
dimension Engel 1977 cultural hermeneutic
model Good and Good 1981 voice of the
lifeworld Mishler 1984) - PATIENT-ORIENTED EVIDENCE THAT MATTERS (POEM)
- MEDICAL HUMANITIES (ethics, philosophy, art,
literature, language/communication etc.)
11SETTING THE HEALTH COMMUNICATION SCENE
- Communication as the beneficiary of
patient-centredness. - Highlighting of communication issues in the
reform of undergraduate medical training, based
on General Medical Councils (2002) Tomorrows
Doctors. - Striving for a balance between core and non-core
training (including Interpersonal Communication
Skills) also in Continuing Professional
Development (see Good Medical Practice, GMC
2001). - Parallel developments via Royal Colleges and
other regulatory bodies.
12COMMUNICATION IN HEALTHCARE AGENDA
- Recognition of communication failure leading to
complaints/litigation - Medical uncertainties about new illnesses
demanding new forms of communication - Increased level of patient access to health
information (the lay expert, especially in the
context of chronic illnesses).
13THE COMMUNICATIVE RELATIONSHIP BETWEEN
PROFESSIONAL CLIENT THE CONUNDRUM
- Good Professional Good Communicator?
CLIENT TYPES
Good Communicator Good Professional??
14COMMUNICATION SKILLS FOR AGAINST
- Patient-centred communication skills unveiled
ideology or ecological practice? - Artificial separation of consulting skills and
communication skills in professional literature
and teaching/training. - Patient-centred models are measured, for example,
by the number of open questions asked, levels of
explanation offered on the assumption that
patients and healthcare providers share the same
communicative resources.
15QUESTIONING THE RELEVANCE OF COMMUNICATION SKILLS
- Patients resistance or dispreference Patients
are primarily concerned with professionals
technical expertise rather than their
communication skills. (Burkitt Wright et al 2004) -
- Recent critique A triumph of evangelism over
common sense! There is not much evidence that
communication skills training makes a difference.
(Williams and Lau 2004) - Attempt to throw the Communication Baby with the
bath water! - Communication/Discourse studies as an invisible
discipline.
16COMMUNICATION IS MORE THAN A SET OF DIY SKILLS
- Communication is not a PILL Limitations of
recipe-style training in A-to-Z of communication
skills which treats symptoms rather than causes
one-sided view of communication where the patient
remains absent potential for de-skilling. - Communicative Competence is not a driving licence
that one passes for lifeneed for ongoing
appraisal to reflect on new challenges. - Communicative Fallacy Models of medical
interaction analysis work with a notion of
form-function equivalence (e.g., open questions
patient-centredness) and thus ignore context
sensitivity and the indexical dimension of
language use.
17A BROADER VIEW OF COMMUNICATION
- Communication is more than information transfer
from sender to receiver via a transparent medium,
channel. - Language form does not determine function.
- There is no one-to-one correspondence between
language form and function. - Meaning is context dependent.
- Communication is jointly accomplished moving
away from a speaker/sender bias.
18PROFESSIONAL PRACTICE AS EXPERT SYSTEM
- Possible relationship between professional
theories and interaction theories (Peräkylä et al
2005) - Different healthcare sites will prioritise
different interactional features based upon their
diagnostic and treatment regimes. - Professionals knowledge of interaction is more
sophisticated than what textbooks and training
programmes suggest. - Interaction is an essential component of the
healthcare expert system. (Sarangi 2005, in
press)
19COMMUNICATION IS A REPERTOIRE OF VARIABLES
- C Code (linguistic, visual, non-verbal etc.)
- O Orderliness
- M Message
- M Mediation
- U Understanding
- N Narrative Style Structure
- I Inferencing Intentionality
- C Context (micro- and macro-levels)
- A Audience, Addressee
- T Tone (feeling, evaluation, key etc.)
- I Identity Role
- O Objective/Goal
- N Norms (social, cultural, interpersonal)
- (Sarangi 2004)
20 - INTRODUCING THE PROJECT
- PARTICIPATING SCHOOLS/COLLEAGUES
21PARTICIPATING SCHOOLS
School of Medicine Institute of Medical Genetics
School of Pharmacy
School of Healthcare Studies
School of Medicine Palliative Medicine
School of Nursing Midwifery Studies
ENCAP
22PARTICIPATING SCHOOLS COLLEAGUES
-
- School of English Communication Philosophy
Professor Srikant Sarangi (Director, HCRC) - School of Medicine Institute of Medical
Genetics Professor Angus Clarke (Director of MSc
in Genetic Counselling) Dr Clara Gaff (Phase 1) - School of Medicine Palliative Medicine (Phase
1) - Dr Anthony Byrne (Director of MSc in Palliative
Medicine) Professor Ilora Finlay
23PARTICIPATING SCHOOLS COLLEAGUES
-
- School of Nursing Midwifery Studies Dr Annette
Lankshear (Director of Graduate Programmes) Dr
Fran Baley (Phase 1) Ms Linda Cooper (Phase 2) - School of Healthcare Studies Dr Nikki Phillips
(Director of MSc in Occupational Therapy,
Physiotherapy and Radiography) Dr Tina Gambling
Ms Dinah Sweet Ms Dawn Pickering - School of Pharmacy Dr Delyth James (Director of
MSc in Community Pharmacy) Ms Karen Hodson
(Director of MSc in Clinical Pharmacy)
24MODES OF ENGAGEMENT
-
- Group Meetings
- Questionnaire data
- Joint data session
- Teaching input
- Co-supervision
- Participation in HEADS seminars,
Interdisciplinary Workshops, Summer Schools - Recorded discussions with course directors
- Targeted data sessions (planned)
25 - THE SCOPING EXERCISE
- SO FAR
26A CHECK-LIST OF PERSPECTIVES
-
- The historical context
- Role of professional/regulatory bodies
- The institutional ethos
- How is communication conceptualised
- Linkage between postgraduate and undergraduate
provision - Potential for intervention
- Challenges for implementation
- Avenues for teaching/training-led collaborative
research
27THE HISTORICAL CONTEXT
-
- Tracing the origin of communication teaching
within each strand. - Micro-skills training based on different models
psychoanalysis, Rogerian therapy, cognitive
behavioural therapy, psychology etc. - Patient-centredness as the main trigger for
foregrounding communication issues - In Genetic Counselling, given the complexities
surrounding genetic disorders with no curative
outcomes, and the long tradition of non-directive
counselling, the onus has always been on
communication issues.
28THE ROLE OF PROFESSIONAL BODIES
-
- The role of Professional bodies such as Royal
Colleges, GMC, MNC, Department of Health and
Learned Associations as well as directives
arising out of government policy in bringing
about communication teaching. Also
recommendations from different Inquiries (e.g.,
Bristol Inquiry). - Differential positioning of professional bodies
- Communicative consequences resulting from changes
in the professional sphere (e.g. striving towards
autonomy from taking doctors orders to
mastering the art of nursing) - Levels of communication competencies (e.g. notion
of advanced communication)
29INSTITUTIONAL ETHOS
-
- Rationale underlying current provision in
communication teaching. What is
included/excluded? -
- How does the Cardiff provision compare with
communication teaching portfolios in other
comparable institutions? -
- Coverage of oral and written language/communicatio
n sites of communication such as
professional-patient encounters,
multi-professional team work). -
- Perceived fit between the multi-faceted role of
communication in professional practice and the
ways in which such communicative trajectories are
reflected in the curriculum (e.g., current
developments in professional practice). -
30INSTITUTIONAL ETHOS
-
- Needs-based, practice-led and research-informed
(e.g., Pharmacy) - Remaining responsive to what undergraduates bring
with them in terms of knowledge, skills,
attitude. - Requiring prior exposure to professional practice
so people make sense of communicative potential
(e.g., work placement in Genetic Counselling) - Flexibility to incorporate new input and design
new assessments, thus allowing the possibility of
uptake from the current project.
31HOW IS COMMUNICATION CONCEPTUALISED?
-
- As a skill-set? Confined to oral interaction
between professionals and clients? Can
communication skills be taught independent of
consulting skills? Any evidence that
communication skills teaching makes a difference?
If not, is it because how communication is
reduced to recipe-style skills? - From communication nowhere/somewhere to
communication everywhere. - Communication across the curriculum as a response
to the limitations of recipe-style skills
training from itemised skills to skills clusters.
32HOW IS COMMUNICATION CONCEPTUALISED?
-
- In favour of theme-driven curriculum
Communication now integral to other modules (e.g.
diagnostic reasoning, compliance, multi
agency/multi professional work) - This marks a shift in communication as a skill to
communication as a host of variables (gender,
power, expertise, difficult patient etc.) - The potential disadvantage associated with the
shift of communication from figure status to
ground status - The risk of taken-for-grantedness in the midst
of professional concerns -
- How to ensure adequate communication analytic
input?
33LINKAGE BEWEEN UG PG PROVISION
-
- Progressive calibration of communication
competencies expected of students at different
end-points - I have done that syndrome
- Communication is a joking matter possible
trivialisation when drawing attention to basics
without content (e.g., nonverbal, dress code
etc.) - The risk of duplication of input, thus making it
non-cumulative - Progressively incorporate complex variables
client-professional to multi-party encounters to
multi-professional decision making to managing
difficult consultations (complex diagnosis,
ethnic/cultural differences etc.) - More integrated, theme-based at PG level
34 35SUMMARY POINTS
- Healthcare communication is constitutive (not an
additive layer) of expert knowledge manifest in
its scientific, clinical and organisational
dimensions. - Healthcare professionals have explicit and tacit
levels of knowledge about interactional
complexity in their specific professional
settings.
36SUMMARY POINTS
- Striving towards a balance between check-list
approach, theoretical approach, experiential
approach and analytical approach. - The analytic processes and outcomes are equally
complex there is a need to recognise different
forms of analytic expertise and move towards
discriminatory expertise, where possible.
37POTENTIAL INTERVENTION CHALLENGES
-
- The success story in MSc Genetic Counselling
(teaching input and assessment) and its resource
implications. - Signs of change (e.g., MSc programmes in Pharmacy
Community Pharmacy and Clinic Pharmacy New
Nursing programme in Advanced Practice to include
a higher dose of communication). - How to implement an integrated, theme-oriented
approach to communication at the level of
teaching/assessment (apparent paradox in specific
Away Days devoted to communication teaching and
role-play based prescriptive model for purposes
of learning and assessment).
38POTENTIAL INTERVENTION CHALLENGES
-
- Explore further scenario-based teaching (include
discourse data simulated or real-life embedding
professional tasks) layers of context and their
analytic significance comparative cases of
good and bad communication when things go
wrong scenarios and their consequence
apprentice-expert encounters reflective learning
potential of self role-plays vs.
others-in-interaction. - From intuitive sense to analytic sensibility
shift from how to communicate to how to
analyse communication in effect transform
teachers clinical experience to communication
expertise. - Targeted data sessions planned as part of
analytic capacity building in the spirit of
complementary expertise.
39POTENTIAL INTERVENTION CHALLENGES
-
- How to translate descriptive, analytic insights
into communication competencies for assessment
purposes. - Reaching beyond already converts
(communicatively speaking!) - Widening access via continued participation in
summer schools, workshops, HEADS seminars. - Develop bibliographies of communication-based
studies in each area. - Maintain a portfolio of co-teaching and
co-supervision.
40AVENUES FOR COLLABORATIVE RESEARCH
-
- Value of teaching/training led research agenda,
triggered by professional concerns. - Such research will inevitably have impact on
teaching and professional practice (e.g.,
Medication Review in Pharmacy). - Analytic frameworks already exist which can be
extended to different sites with minimum effort. - Dissemination of findings in journals and at
conferences (e.g., integrating communication
skills and counselling skills in genetic
counselling courses).
41CHALLENGES FACING THE FUTURE AGENDA
-
- Negotiation of curricular space for communication
(e.g., integration as core skill can lead to
neglect). - Responsiveness of students to new modes of
teaching communication. - Staffing resources SS and training of trainers.
- Difficulty in sustaining the ongoing programme of
activities the current inter-school scenario (in
terms of losers and gainers) and lack of support. - Can the barriers (not obstacles) be addressed
at the university level?