Initially I chose “Clinical Skills” as the title for my book. Later I decided on “Clinical Competency Skills” at the suggestion of an editor. I know what the word “competence” means. As usual, a common word takes a special meaning when it enters the lexicon of a profession or a trade. In medicine, competence is defined as “ the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individuals and communities being served”. I prefer the simple definition, which is “capacity equal to requirement”.
There are several components to competency. The first requirement is that the physician is able to relate to people in distress and make them comfortable. In other words, he has human relationship skills. Knowledge is of paramount importance without which human relation skills are of no use, and may even be dangerous. The physician needs listening and communication skills. He needs procedural skills and clinical reasoning skills. Above all, he has to be able to reflect on daily experiences and keep improving all his skills all the time.
It is easy to enumerate the components of competency. How does one teach competency? How does one assess competency? A recent article on Assessment in Medical Education summarizes some of the domains within the realm of competency and methods of evaluation. I found Table 1 in this article very useful to think about competency in general and the difficulties in assessing competency.
Epstein RM. Assessment in Medical Education. N Engl J Med 2007; 356:387-96. www.nejm.org
Klass D. Assessing Doctors at Work – Progress and Challenges. N Engl J Med. 2007; 356:414-15. www.nejm.org
Tuesday, June 23, 2009
Communication Skills and Patient Safety
Recently I attended a talk by Mr. Bill Taggart of University of Texas (at Austin). The topic was “ Lessons learned from Aviation – Practical skills that actually work”. The talk was excellent. If you wish to arrange for Mr.Taggart to give grand rounds at your Hospital, you may wish to reach him at the Human Factors Research Project at the University of Texas at Austin. (e mail address: BTaggart@aol.com) Mr.Taggart is the developer of Crew Resources Management Program that is used routinely by major airlines in US and abroad. More recently, he has started applying lessons learned in aviation industry to patient safety issues.
The topic is very important and timely. There are two additional reasons I am writing about this topic. 1.In my Handbook of Clinical Skills, I talk about learning from other professions. Here is an excellent example of learning from the aviation industry. 2. In his talk Mr.Taggart presented data collected between 1995-2005 by the JCAH on the root causes of sentinel events, surgery at wrong sites and perinatal injuries and deaths. In all of them, communication failure is on the top of the list.
When I condensed Mr.Taggart’s entertaining talk to a few “sound bites” with focus on communication (he talked about other topics too), here is what I got:
Focus has to be on the patient, But
Physician must know the big picture
Pay close attention to what the patients (and parents in pediatrics) have to say
Describe what you see (not impressions and interpretations)
Be clear and precise with the words you use to describe (no euphemisms, vague remarks)
Use the correct words to show the urgency of the situation
The topic is very important and timely. There are two additional reasons I am writing about this topic. 1.In my Handbook of Clinical Skills, I talk about learning from other professions. Here is an excellent example of learning from the aviation industry. 2. In his talk Mr.Taggart presented data collected between 1995-2005 by the JCAH on the root causes of sentinel events, surgery at wrong sites and perinatal injuries and deaths. In all of them, communication failure is on the top of the list.
When I condensed Mr.Taggart’s entertaining talk to a few “sound bites” with focus on communication (he talked about other topics too), here is what I got:
Focus has to be on the patient, But
Physician must know the big picture
Pay close attention to what the patients (and parents in pediatrics) have to say
Describe what you see (not impressions and interpretations)
Be clear and precise with the words you use to describe (no euphemisms, vague remarks)
Use the correct words to show the urgency of the situation
Communication Skills and Listening
Common sense observation tells me that “listening” is a good thing particularly when you are helping someone who is grieving. I do not need “science” to prove that listening is good. But, it is easier to convince others with actual observations and scientific data.
In a recent article on this subject, investigators from France report on a prospective, controlled trial in which 126 family members of patients dying in ICU’s were randomly assigned to a formal intervention group or routine care group. The intervention group received care according to detailed guidelines developed specifically for end-of-life care. Outcomes were defined and appropriate statistical tools were used for analysis. The authors conclude that “using a proactive communication strategy that includes longer conferences and more time for family members to talk may lessen the burden of bereavement”.
There is an accompanying editorial that points out “A key skill is listening more and talking less”. It is the same as what Plutarch said several centuries back: “We have two ears and one tongue so we may listen twice as long as we talk”!
Most of us learn how to communicate with patients and how to comfort those in distress by just observing a few sensitive clinicians. It is definitely important to develop tools that help young physicians learn some of the principles of communication under different circumstances. The authors of the above-quoted study give a mnemonic to remember the steps in this process of bereavement-counseling. It is: VALUE.
Valuing and appreciating what the family members have to say
Acknowledging the emotions expressed by the family members
LISTENing
Understanding who the patient was as a person, by listening to family members
Eliciting questions from the family members.
References:
Lautrette A et al. A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med 2007: 356: 469-78.
Lilly C, Daly BJ. The healing power of listening in the ICU. N Engl J Med 2007; 356: 513-15.
Curtis JR et al. The family conference as a focus to improve communication about end-of-life care in the intensive care unit: opportunities for improvement. Crit Care Med 2001; 29: suppl 2: N26-N33.
In a recent article on this subject, investigators from France report on a prospective, controlled trial in which 126 family members of patients dying in ICU’s were randomly assigned to a formal intervention group or routine care group. The intervention group received care according to detailed guidelines developed specifically for end-of-life care. Outcomes were defined and appropriate statistical tools were used for analysis. The authors conclude that “using a proactive communication strategy that includes longer conferences and more time for family members to talk may lessen the burden of bereavement”.
There is an accompanying editorial that points out “A key skill is listening more and talking less”. It is the same as what Plutarch said several centuries back: “We have two ears and one tongue so we may listen twice as long as we talk”!
Most of us learn how to communicate with patients and how to comfort those in distress by just observing a few sensitive clinicians. It is definitely important to develop tools that help young physicians learn some of the principles of communication under different circumstances. The authors of the above-quoted study give a mnemonic to remember the steps in this process of bereavement-counseling. It is: VALUE.
Valuing and appreciating what the family members have to say
Acknowledging the emotions expressed by the family members
LISTENing
Understanding who the patient was as a person, by listening to family members
Eliciting questions from the family members.
References:
Lautrette A et al. A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med 2007: 356: 469-78.
Lilly C, Daly BJ. The healing power of listening in the ICU. N Engl J Med 2007; 356: 513-15.
Curtis JR et al. The family conference as a focus to improve communication about end-of-life care in the intensive care unit: opportunities for improvement. Crit Care Med 2001; 29: suppl 2: N26-N33.
Humor- When and How to use
I learnt recently that the word humor is etymologically related to the word humility. Good humor is kind and compassionate. It makes us laugh at human follies. The word seems to have another connection – with the humors of Hippocrates. According to his theory, when humors “flow” normally, one is in good health. Irregular flow of humors leads to ill health (or ill humor).
A sense of humor is essential in life – particularly in a physician’s life. Humor and laughter are helpful for patients in their recovery. However, physician’s work is serious. Good clinicians know when to use humor and when not to. Inappropriate jokes and bad timing can land you in trouble. I believe that patients do not worry as much about your sense of humor as about your knowledge and expertise. They may not like physicians who are too serious or morose. But I do not think they want a clown either.
I am a serious person by nature, and like to use humor sparingly. However, I love good jokes. In fact, I have been collecting medical jokes and have a whole file on them. Hope to share some with you periodically.
Here is a start. This one is by Art Buchwald in an essay on humor in JAMA (252:3014,1984). “If laughter is such good medicine, why won’t Medicare and Medicaid pay for it?”.
Here is another one from Henny Youngman who was famous for his one-liners. This is about a hotel room he was staying in. “ My room is so small, the mice are hunch-backed”.
A sense of humor is essential in life – particularly in a physician’s life. Humor and laughter are helpful for patients in their recovery. However, physician’s work is serious. Good clinicians know when to use humor and when not to. Inappropriate jokes and bad timing can land you in trouble. I believe that patients do not worry as much about your sense of humor as about your knowledge and expertise. They may not like physicians who are too serious or morose. But I do not think they want a clown either.
I am a serious person by nature, and like to use humor sparingly. However, I love good jokes. In fact, I have been collecting medical jokes and have a whole file on them. Hope to share some with you periodically.
Here is a start. This one is by Art Buchwald in an essay on humor in JAMA (252:3014,1984). “If laughter is such good medicine, why won’t Medicare and Medicaid pay for it?”.
Here is another one from Henny Youngman who was famous for his one-liners. This is about a hotel room he was staying in. “ My room is so small, the mice are hunch-backed”.
Humor - Art Buchwald
I am sad that Art Buchwald is no more with us. Only recently I completed reading his last book with the title “Too soon to say goodbye”. He says: “Doctors gave me three weeks to live. I never knew dying could be so much fun”. What an attitude to death! Or, Is it attitude to life?
It is amazing to read about his refusal to go through dialysis, accepting a life in a Hospice, having fun meeting people and writing this book and even organizing his own funeral.
There are quotable remarks all though the book. Here are a few about his stay at the Hospice:
“How long they allow me to stay is another problem. But in case you are wondering, I am having the best time of my life.”
“Dying isn’t hard. Getting paid by Medicare is”.
“Being 80 is a matter of life or death. I chose life. It is much better position to be in, and it is easier on your back.”
“At a certain time in life, actually right now, the two questions that become uppermost in my mind are: What am I doing here? And where am I going? The first one is a narcissistic one. I was put in this world to make people laugh. The second one is much harder – I have no idea where I’m going, and no one else either”.
Art, thanks for making us laugh.
It is amazing to read about his refusal to go through dialysis, accepting a life in a Hospice, having fun meeting people and writing this book and even organizing his own funeral.
There are quotable remarks all though the book. Here are a few about his stay at the Hospice:
“How long they allow me to stay is another problem. But in case you are wondering, I am having the best time of my life.”
“Dying isn’t hard. Getting paid by Medicare is”.
“Being 80 is a matter of life or death. I chose life. It is much better position to be in, and it is easier on your back.”
“At a certain time in life, actually right now, the two questions that become uppermost in my mind are: What am I doing here? And where am I going? The first one is a narcissistic one. I was put in this world to make people laugh. The second one is much harder – I have no idea where I’m going, and no one else either”.
Art, thanks for making us laugh.
Clinical Measurements
Recently, I was reviewing the literature for articles on measurements of height, weight, BMI etc infants and children. I was amazed to note that there are at least 3 different methods for measurement of chest circumference. Fortunately, the articles describe the method clearly. That is how I know they are different. However, textbooks assume you know which method to use, when they refer to normal chest circumference.
I found the same situation when reviewing articles on waist to hip ratio as a mark of obesity. I reviewed three articles and found three different methods. The more recent ones are consistent with each other. How does one establish an acceptable method?
We insist on the accuracy, reliability, and reproducibility of laboratory values. Why not insist on these characteristics for clinically important measurements?
I found the same situation when reviewing articles on waist to hip ratio as a mark of obesity. I reviewed three articles and found three different methods. The more recent ones are consistent with each other. How does one establish an acceptable method?
We insist on the accuracy, reliability, and reproducibility of laboratory values. Why not insist on these characteristics for clinically important measurements?
Monday, June 22, 2009
Listening Skills
Listening to parents (and patients)
During my residency days, I saw a 20 months old child who was brought in by his mother with the chief complaint of “ my child weighs heavy”. There was no other complaint. Physical examination was normal. It is possible that I missed minimal edema during physical examination. But I did not ignore her complaint, because in pediatric practice the dictum should be “Trust what mother says, until proven otherwise”. On examination of the urine I noticed significant proteinuria. Subsequently we found that the child was in the early stages of acute glomerulonephritis.
The example outlined in the first paragraph is about listening to parents and doing something about their concerns. How do we know what the concerns of parents are? An essay on “Listen to the parents – They may know best” (BMJ 313: 954, 1996) refers to an article on the information needs and experience of parents of children with a recent acute viral illness. The parents needed information on the following items: How can I gauge the severity of illness?
How do I know when to seek advice?
What is virus illness? (What do you mean by virus? Where does it come from? In other words, could I have done something to prevent it? In other words, was I a bad mother?)
How do antibiotics work?
What is the experience of other mothers?
Some interesting quotes were: “ The doctor said it was a virus and needed no treatment and then a few days later the other doctor gave the antibiotics”. “You just get palmed off……you sort of feel let down….disheartened… sometimes you feel as though may be they are not listening to what you are saying”.
Here is an important point. It is not adequate that you think you are truly listening. It is how the parents perceive that counts. Their perception depends on your body-language and listening habits. It also depends on what you do with what you heard. If you do not address their concerns specifically, they go away thinking that you did not listen.
It is obvious that parents need information developed to suit their needs and abilities. We cannot know what their needs and abilities and constraints are unless we LISTEN carefully.
During my residency days, I saw a 20 months old child who was brought in by his mother with the chief complaint of “ my child weighs heavy”. There was no other complaint. Physical examination was normal. It is possible that I missed minimal edema during physical examination. But I did not ignore her complaint, because in pediatric practice the dictum should be “Trust what mother says, until proven otherwise”. On examination of the urine I noticed significant proteinuria. Subsequently we found that the child was in the early stages of acute glomerulonephritis.
The example outlined in the first paragraph is about listening to parents and doing something about their concerns. How do we know what the concerns of parents are? An essay on “Listen to the parents – They may know best” (BMJ 313: 954, 1996) refers to an article on the information needs and experience of parents of children with a recent acute viral illness. The parents needed information on the following items: How can I gauge the severity of illness?
How do I know when to seek advice?
What is virus illness? (What do you mean by virus? Where does it come from? In other words, could I have done something to prevent it? In other words, was I a bad mother?)
How do antibiotics work?
What is the experience of other mothers?
Some interesting quotes were: “ The doctor said it was a virus and needed no treatment and then a few days later the other doctor gave the antibiotics”. “You just get palmed off……you sort of feel let down….disheartened… sometimes you feel as though may be they are not listening to what you are saying”.
Here is an important point. It is not adequate that you think you are truly listening. It is how the parents perceive that counts. Their perception depends on your body-language and listening habits. It also depends on what you do with what you heard. If you do not address their concerns specifically, they go away thinking that you did not listen.
It is obvious that parents need information developed to suit their needs and abilities. We cannot know what their needs and abilities and constraints are unless we LISTEN carefully.
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