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1 Fostering patient-centredness in future doctors: more than skills... Katrien Bombeke Symons L, Debaene L, Schol S, De Winter B, Van Royen P Because Health 2012

2 Medical students and patient-centredness? Is there hardening of the heart? The decline and fall of humanism The detrimental ethical shift towards cynicism Vanquishing virtue How can we stop the rot? The devil is in the third year Colliver et al. Acad. Med

3 Outcome-based medical education 2

4 ASE-model de Vries, Kok, Fishbein, Ajzen, Bandura Attitude Social influence self Efficacy Intention Behaviour 3

5 ASE-model de Vries, Kok, Fishbein, Ajzen, Bandura Attitude Social influence self Efficacy Intention Behaviour 4

6 Communication skills training Aspegren (BEME 1999) Skills: overwhelming evidence experiental learning = small groups DO & feed-back (patients!) helical structure integrated in the curriculum (van Dalen) 5

7 T1 T2 T3 T4 T5 T6 T7 Ba 1 Ba 2 intro structuur consult intake actief luisteren A-Pt relatie 1 actief luisteren basic skills nonverbaal communicatie op stage interview verpleegstage anamnese dooroefenen reflectie Ba 2 reflectie stage Ba 3 attitude 1 attitude 2 interview arts emoties emoties hanteren attitude & emotion informeren motiveren kinderen, pubers 1 Ma 1 Ma 2 slecht nieuws conflict A-Pt relatie 2 interview chron. pt psychiatrie 1 ouderen, levenseinde psychiatrie 2 psychiatrie 3 advanced skills, integration psychiatrie 4 ALOBA 1 ALOBA 2 ALOBA 3 kinderen, pubers 2 Ma 3 CLINICAL YEAR portfolio Ma 4 GP-TRAINEES: advanced training, specific skills (e.g. palliative) 6

8 T1 T2 T3 T4 T5 T6 T7 Ba 1 intro nonverbal active listening active listening communi cation on the ward interview nursing att. reflection nursing att. Ba 2 structure intake relationship 1 history taking exercises reflection Ba 2 Ba 3 attitude 1 attitude 2 interview arts emoties emoties hanteren attitude & emotion informeren motiveren kinderen, pubers 1 Ma 1 Ma 2 slecht nieuws conflict A-Pt relatie 2 interview chron. pt psychiatrie 1 ouderen, levenseinde psychiatrie 2 psychiatrie 3 advanced skills, integration psychiatrie 4 ALOBA 1 ALOBA 2 ALOBA 3 kinderen, pubers 2 Ma 3 CLINICAL YEAR portfolio Ma 4 GP-TRAINEES: advanced training, specific skills (e.g. palliative) 7

9 T1 T2 T3 T4 T5 T6 T7 Ba 1 intro nonverbal active listening active listening communi cation on the ward interview nursing att. reflection nursing att. Ba 2 structure intake relationship 1 history taking exercises reflection Ba 2 Ba 3 giving information attitude 1 attitude 2 interview emotions dealing with emotions motivatio nal interv. children & adol. 1 Ma 1 Ma 2 slecht nieuws conflict A-Pt relatie 2 interview chron. pt psychiatrie 1 psychiatrie 2 psychiatrie 3 advanced skills, integration ouderen, levenseinde psychiatrie 4 ALOBA 1 ALOBA 2 ALOBA 3 kinderen, pubers 2 Ma 3 CLINICAL YEAR portfolio Ma 4 GP-TRAINEES: advanced training, specific skills (e.g. palliative) 8

10 T1 T2 T3 T4 T5 T6 T7 Ba 1 intro nonverbal active listening active listening communi cation on the ward interview nursing att. reflection nursing att. Ba 2 structure intake relationship 1 history taking exercises reflection Ba 2 Ba 3 giving information attitude 1 attitude 2 interview emotions dealing with emotions motivatio nal interv. children & adol. 1 Ma 1 breaking bad news relationship 1 psychiatry 1 psychiatry 2 psychiatry 3 psychiatry 4 intercult. com. Ma 2 conflict interview chron. pt elderly ALOBA 1 ALOBA 2 ALOBA 3 children & adol. 1 Ma 3 CLINICAL YEAR portfolio Ma 4 GP-TRAINEES: advanced training, specific skills (e.g. palliative) 9

11 ASE-model de Vries, Kok, Fishbein, Ajzen, Bandura Attitude Social influence self Efficacy Intention Behaviour 10

12 Attitudes inner evaluation of a specific patient-centred action inner motor vs. faking behaviour! 11

13 In communication skills training, they just put some standard phrases into your mouth. Then you try to use them but that just comes across as very affected so in reality I d never do it like that! But now you have to because if you don t, you have a bad consultation, you can t communicate and you flunk Student, year 4 Bombeke K, Symons L, De Winter B, Vermeire E, Debaene L, Schol S, Van Royen P. Patientcentredness from education to practice: the lived impact of communication skills training. Medical Teacher 2012;34:e338-e

14 Attitudes inner evaluation of a specific patient-centred action inner motor vs. faking behaviour! attitude development is important How can we foster students patient-centred attitudes? 13

15 Attitudes inner evaluation of a specific patient-centred action inner motor vs. faking behaviour! attitude development is important How can we foster students patient-centred attitudes? Too much pressure allergic reaction Relevance of skills training: early clinical exposure Relevance of skills training: scientific evidence Realistic message vs idealistic Teaching attitudes vs raising awareness of own attitudes 14

16 ASE-model de Vries, Kok, Fishbein, Ajzen, Bandura Attitude Social influence self Efficacy Intention Behaviour 15

17 During my first week I was absolutely astounded by the way doctors treated their patients. Like they weren t human to them. But after one week, I caught myself behaving like that too. You kind of roll into it and fall into that way of thinking, too. student, year 7 During the clinical clerkship year you want good grades. And it s not by being patient-centred that you get good results. A lot of students want to secure sufficient marks to get selected, that brings a lot of stress. specialist trainee Bombeke K, Symons L, De Winter B, Vermeire E, Debaene L, Schol S, Van Royen P. Patientcentredness from education to practice: the lived impact of communication skills training. Medical Teacher 2012;34:e338-e

18 Hidden curriculum! Powerful impact of the system Social influence Patient-centredness should be part of the clinical assessment Faculty development Every single role model is important Communication trained students are the role models of the future 17

19 ASE-model de Vries, Kok, Fishbein, Ajzen, Bandura Attitude Social influence self Efficacy Intention Behaviour 18

20 Self-efficacy = Confidence in your own capability of providing patient-centred care. Practising is important! Early patient exposure and feedback. From safe ideal training floor to challenging realistic training floor TRANSFER Instrumental strategy (Walqvist et al.) = a development phase, if students are sufficiently supported 19

21 Because you feel more relaxed and confident, you leave more room for the patient. Initially you must have a diagnosis. Later on you dare to deviate from you standard list and other things come up specialist trainee In the clinical year you see that it s not at all what you had expected. You want to be a good communicator and you think you are, but it is not true Frustrating! specialist trainee I really do feel that the communication training we got prepared me for working with patients. GP trainee Bombeke K, Symons L, De Winter B, Vermeire E, Debaene L, Schol S, Van Royen P. Patient-centredness from education to practice: the lived impact of communication skills training. Medical Teacher 2012;34:e338-e

22 ASE-model de Vries, Kok, Fishbein, Ajzen, Bandura Attitude Social influence self Efficacy Intention Behaviour 21

23 Bombeke K, Symons L, Debaene L, De Winter B, Schol S, Van Royen P. Help, I'm losing patient-centredness! Experiences of medical students and their teachers. Med Educ. 2010;44:

24 23

25 24

26 25

27 ASE-model de Vries, Kok, Fishbein, Ajzen, Bandura Attitude doctor-as-person Social influence self Efficacy intention behaviour 26

28 Personal development Emotions emotional blunting Personal suffering, life history, background Self-care Self-awareness Doctor-as-person 27

29 Doctor-as-person Self-reflection Mindfulness Tutorship: individual (portfolio) and small-group (clerkship year) Communication model vs. unique personal style Longitudinal mentor, patient Lancet-report transformative learning: systems-based reform to produce enlightened change agents Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010;376:

30 Triple loop learning 29

31 from patient- to people-centredness Instructional reforms transformative learning fact memorisation searching, analysis and synthesis of info for decision making seeking credentials achieving core competencies for effective teamwork in health systems non-critical adoption of educational models creative adaptation of global resources to address local priorities Institutional reforms interdependence isolated harmonised education and health systems stand-alone institutions networks, alliances and consortia inward-looking institutional preoccupations harnessing global flows of educational content, teaching resources and innovations 30

32 31

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