Collection of resources for the learning and teaching of communication skills

Teaching

I had no formal training [in communication skills]... apart from what we saw and heard in the demonstration clinics... the people holding those were other similarly ungifted, older dentists, or even sometimes people that’s a couple of years older than us (Dentist talking about role models and communication learning. BMJ 2018)

Value proposition for learning additional communication skills:

 

How to make learning of communication skills better/easier/more effective.

  1. Science of learning
    From - Making it stick : Science of better learning (good book)
    1. Retrieving knowledge from memory has the effect of making that knowledge easier to call up again in the future.
      1. Repeated retrieval strengthens memory because the act of retrieving a memory strengthens the memory, making it easier to retrieve later.
      2. Retrieval must be spaced out and require some cognitive effort.
      3. Testing is an important retrieval technique. Testing interupts forgetting. Simply asking someone to fill in a word's missing letters results in better memory of the word! (generation effect)
    2. Delaying feedback produces better long-term learning (even though it feels counter intuitive). So if you keep interupting with feedback you can imped deep learning .e.g.. like learning to ride a bike with training wheels - learner becomes dependent on the trainers and so learning task actually takes longer.
      Also it is felt that frequent interruptions for feedback make the learning session too variable, preventing an established pattern of performance.
    3. My thoughts - (if people believe that doing something well has a randomness element in it then they may not feel that retrieval practice will improve the outcome - this is especially true where they don't have any cognitive elements to link to controlling a better outcome. e.g.. I will waste the good tennis shot because sometimes I do it well and I am not sure why)
    4. Working memory: We have a fixed working memory and use it in the process of retrieving information. If your working memory is also occupied in worrying about not doing something correctly; what people are thinking of me etc then there is less room for retrieval of important information.
      1. People who don't "believe" in making errors or see it as failure will do worse in exams because we have a fixed working memory and if you occupy it with fear of error then there is less working memory to do the test. Being penalised for errors in learning can reinforce fear of errors and be a hinderance to deeper learning and understanding.
    5. The best exam prep is "doing" ; "testing" and the worst is just reading over material because unless the task involves retreiveal of information from memory it doesn't get "better processed" into the retreival base in your mind.

Hinderances to acquiring or using additional communication skills

  1. Belief issues
    • Cultural expectations about dentists and doctors. Are my values inhibiting my adoption of additional communication skills? Are dentists are the people with the knowledge and "position" of authority and control?
    • Do I believe that dentist has the knowledge and the patient has the answer?
      (No, that doesn't mean the patient knows what the answer is!)
      Health diagnosis and treatments can be a very complex algorithm. In teaching there is often the need to simplify the algorithm both for learning and assessment.
      Diagnosis is the art of asking better questions.
      The quality of the answer from the patient is the dentist's responsiblity and relies on the quality of the dentist's questions.
      The quality of the dentists questions increases with the dentists knowledge. Students often say to the patient -"Tell me about your problem"- if the patient describes their problem as "x" and you give them the solution to "x", then haven't you fulfilled the requirements of the task? It can be hard to explain that diagnosis is the skill of asking questions to understand as much as possible so that you can deliver good health outcomes. e.g.. if someone has a clean fracture cusp: if you actually knew they chomp on frozen lollies does that change your solution?
    • Do I believe that patients decisions are fixed and logical? [Behavioral economics, Motivational interviewing change talk, understanding that health isn't what we do but what has been down to us, Neurolinguistic programing etc etc]
  2. Believes that communication skills are not learned skills. Belief that their core values/being/integrity will be lost if they use communication skills. (Solution is to let them live with a 3 year old and see how much of "who we are" is the result of parenting.) Lack of responsibility for how their communications effects others. Lack of awareness of the unintended consequences of what they say.
  3. Lack of balance when teaching communication
    We are asking for some change in present communication so it is good to remember that:
    Change = (Knowledge + Vision + Skill ) X Confidence
    As a teacher we may have preferences towards one aspect to change.
    For communication learning
    Knowledge: Make sure you can define the communication strategy that you are trying to teach and not just a example of it. If you don't know "what" it is then there is a high likelihood of the student not "getting it". e.g.. co-discovery techniques; reasons for summary (how does it benefit the clinician); small chunks; checking in; teach-back; righting reflection.
    Vision: Everyone is surviving very well thank you with their existing communication skills. What is in it for them to bother to try something else. The research from the Calgary-Cambridge model suggests that medical students only do those things while they are being evaluated in an academic situation! So for dental students - Cidgem Kipels podcast about saving time; efficiency and being able to use it to gain better job satisfaction. Students and many dentists will resonate with the feeling of "pushing the barrow uphill" with getting patients to do "what we want". Imagine if you could lessen the load.
    Skills: Make available opportunities for students to try new communication skills in a safe environment (batting practice). Communication is like dentistry in that it is 'close to our soul" and there are big opportunities to feel judgment, fear and shame.
    Confidence: There is a great fear that communication change = sales; a fear that you will be asking a person to be a lesser version of themselves; a feeling that communications is not really a learnable skill - because we have no conscious recall of the time and effort our parents and teachers put in or the cultural norms embedded in communication. (e.g.. eye contact with elders - indigenous and other cultures; please , thank you, comedy with physical damage; ) - see judgment, fear and shame. Talent = speed at acquiring a new skill

 


Calgary-Cambridge model for communication

Marrying Content and Process in Clinical Method Teaching: Enhancing the Calgary–Cambridge Guides
https://bmjopen.bmj.com/content/bmjopen/4/3/e004339.full.pdf?with-ds=yes

Resources for teaching especially where English is not your first language

Basic outline to use with Calgary-Cambridge model

  1. Introduction: clear respectful
  2. Good opener: For Example
    "Welcome Jane and I understand that you spoke to Amy our receptionist and you said that something on the left has chipped but if it is ok I would like to get you to start at the beginning and tell me about your past dental history, any treatment you have had , anything you've had done, that is leading what is bothering you now."
  3. Listening skills: (Handing over the microphone) Biggest thing to learn is how to structure the communication to get the patient talking more. Ask better questions and talk less:
    Stop and let the patients chime in: (after 20 sec)
  4. Good questions to encourage the patient to elaborate about their dental history/ drill down into things they say. Aim is to find out both for diagnosis of their condition and their values -what they would value in a dentist.
    Ask open ended questions to show GENUINELY curiosity; care and real genuine interest :
    1. so when did you notice that.
    2. and I am curious about what that felt like
    3. Is this something you were aware of previously?
    4. and how long ago did that happen
      [How are you making the patient feel in your questions? Do they feel you are genuinely interested in them? What are you doing to make a patient feel like that? Body language; position; contact]
  5. Empathy and attention to feelings: People don't remember what you say or do; they just remember how you made them feel (easy to make people feel embarrassed, judgment and shame because people are really sensitive about this part of your body e.g.. when did you last get a clean; how do you feel about the color or your teeth...CAN ALL BE VERY EMBARASSING
    Show your patients that you care—that’s what all customers are looking for! Patients, after all, may not remember what you said or even what you did. But, they always will remember how you make them feel.
  6. Non-jargon explanation for all dental conditions

    If you can't explain it simply, you don't understand it well enough.– Albert Einstein
    Keep it short (1-2 sentences) Explain in terms that relate what it means to the patient; not in terms of how it is done. e.g. a crown is something that covers the tooth to minimise the risk of fracture - instead of that you are going to cut a layer all around the tooth and take an impression and send it to the lab. (this is just how we think of things procedurally and technically)
    Do not teach dentistry to the patient. You don't need to go deep into the procedural part of things, what they need to know what it means to them and what are the downsides. (explain the benefits and not the procedure e.g... what does it mean to them). You do need to give the patient the opportunities to ask more about the "how" but this is not the starting point.
    Develop a list of sentences that you can always use: e.g.. Dental conditions (under development because I think this is quite hard!)

    • Dental caries or dental decay: is a hole in the tooth that, unless something is done to stop the hole getting bigger, will get so big that not enough tooth will be left to ever fix the tooth.
    • Periapical abscess: bag of pus in the bone at the end of your tooth.
      Dental treatments
    • Crown : cover or cap that protects and overlays a tooth so it envelops a split in that tooth so that when you chomp down, you can chomp knowing that the tooth is unlikely to be split any further.
  7. Aiding accurate recall and understanding
    Simple structure (for each condition) Condition -options - decision.
    Condition - what it is; where it has progressed to and what they can expect if it continues along that way. Use co-discover if possible.
    (This is what a patient should have (how does health look); This is what the patient has now; What happens if it is not attended to or progesses)
    Once patient understands that they have a condition; they can take ownership of what they have been diagnosed with; they have the control and power to make a better decision for themselves.
    Always point out an example of a healthy tooth and why it is healthy (color, shape) and "this is an example of a really healthy tooth, and a really great crown/filling...and can you see the difference over here on this tooth (and stop talking) let them say it (so it is revealed to you and the patient at the same time so you don't need to convince them of anything - you are co-discovering it) The patient will be far more motivated to do something about it if they understand it.
    Option (see below): Pros and cons, cost.
    You never want to talk to long without the patient buying in-ways to bring them back into the conversation.
    Prompting questions:
    1. Am I making sense so far?
    2. I am sensing this is a bit of surprised to you?
    3. Is this along the lines of what you were expecting?
    4. is this something you have previously been made aware of?
    5. What are your thoughts?
  8. Shared decision making: Not treatment plan presentation - it is a treatment option discussion. It is not a one-way pitch. It is a two way discussion and we need to be adaptable to our patients. Not acceptance versus rejection scenario- treatment option discussion and reach a treatment option conclusion.

    Clarify your treatment options in your head -[ as simply as possible; optimal and alternative. Be decisive and keep it simple; rough sequence - starting with the patients chief concern. ]
    Presenting to the patient: Give options and not recommendations because:

    • Control (patient feels they are in control)
    • Avoids the accept vs reject scenario
    • You don't own the problem - the patient does
    • Choice is entirely up to the patient- you want to remain in the position of the advocate for the patient (they may have lots of other needs)
    • Give 2 choices - don't overwhelm (e.g.. it may be between fixed and removable - then if they pick fixed ,then other choices.

    Ask permission to give the options to the patient. (so this is to make the options accessible to the patient. e.g.. I am just here to give you the range - some people do this and some people do that). Alternative: "Peter we have seen that there is a bit of an issue with one particular tooth, but don't worry, we can fix it but there are a number of options for you ... so what can I tell you first (this is designed to get the patient "present" with you and engage them otherwise they are thinking a mirearde of things and you cant be sure what they are- are you even answering a question that they have)
    Don't create unnecessary and irrelevant questions - e.g.. we are going to make a zirconium crown then the person asks what is a zirconium crown (when in fact that decision is for the dentist to make) Don't give them decisions that they don't need to make. e.g... this kinds of splint or this type of splint. You should be making those decisions.
    Bundle for simplicity e.g... endo with a crown as one item if this is what they need
    Risk discussion - you probably wont do all the risks for everything so maybe leave specifics to the phase where they have made their primary decision. (use your common sense with this)
    A commitment to re-booking is success (retention and referral. = success)
    Decisions and commitment: Goal = crystal clear commitment of next step

    • Prompting questions:
      What would you like to do?
      Which option would suit you best?
      How does that sound?
      Which way are you leaning?
      What are your thoughts so far? ( you want to open up the conversations so you can understand and discuss the barriers)
    • For more understanding of what can "nudge" people towards certain decisions - see my page on behavioral economics

  9. Closure: Clear next step - no doubt, no confusion.

-------------------------------------------------

Technical language (jargon) philosphy

Jargon removal : developing explainations that are patient focused.
Traditional system of developing explainations for dental conditions and treatment for patient was that as students we are taught the scientific basis of dentistry. From there we will develop ways of making the information and knowledge we must hold for exams, as accessible to ourselves for recall. It is this information that we then must convert into "patient friendly explainations". Hence, even when it is jargon free, the primary purpose of the information may not be to make it relevant to the patient experience and need for better health. It may always remain as less jargon version of the information we need to explain the science to ourselves and our past examiners.

How not to speak - dont use jargon
Can you drop all technical term and make it language most anyone can understand? You are not talking to a dentist. They may be very intelligent but they may not have "dental language".

-------------------------------------------------

Communicating health podcast - Dr Colm Harney
Dr Aengus Kelly Oct 21 2019 - hear the "I hate the dentist" conversation, talking about burnout. Anxiety- Sensory Adaptive Dental environment. Giving patients a control cue. Asking permission. Confidence, assertive with humility.

Against empathy - Paul Bloom (Book)
Introvert power. Give and Take - Adam Grant. The overstory by Richard Powers

-------------------------------------------------
Presenting for a communications exam on zoom

1. How you present yourself
Zoom hints (try these things on your iphone - flip so you can see how you look:

  1. Lighting - have a window or light in front of your face, not behind you
  2. Check out your surrounds - declutter and clean looking
  3. Camera angle - just slightly above your face. e.g.. put your laptop on books and check out the distance to your face
  4. Clothing - look like you are respecting the process e.g.. makeup and professional appearance

How to introduce yourself (4.35)

In the first seven seconds people make decisions about you - see video (12.9)

 

------------------------------------------------------------
Managing your communications in the real world (which includes communication exams)

Think fast; talk smart (58 minutes) Matt Abrahams
This talk has excellent exercises to practice his suggestions. Listen to the end for great info.

Presenting a treatment plan to a patient
Know why you are here and be confident about about it -e.g. you are here to help your patient have /gain good dental health for life? (6 min).

-----------------------------------

Validation:
What not to say (article in new window) esp what not to say no. 2 I'm sorry you feel that way!

Check out this video (4.17) esp the way to react to a patient who may say something that doesn't fit in with your spiel

-----------------------------------------

Empathy
Motivational Interviewing and learning the language of empathy - podcast: https://www.glennhinds.com/motivational-interviewing/ep-33-mi-in-dietetics/. I found this was very helpful in thinking about empathy.
Do you genuninely have the persons best interests at heart? (this is sales youtube)

 

 

How not to explain something to a patient (5 min) and how not to get informed consent

-----------------------------------------------------------------------------

Motivational interviewing
This is a means of intentionally being aware that when a person is conflicted (ambivalent) about something. What we say to a person can influence that persons choices within that conflict. It also is being aware that we may be able to influence whether a person becomes conflicted about something by what we say/do/show. Remember the aim of advertising is to find someones conflict or cause it and then use it to move a person towards a choice.

Using motivational interviewing in primary care


Motivational interviewing (34minute explaination)- motivating people who are ambivalent (behaviour change)

Informed consent
Practical Dental Consent A practical Guide to the Consent Process (Brad Wright Barrister Aust Dentist)
Consent for Dental Treatment Checklist (Brad Wright Barrister Aust Dentist)

What not to do (3 )

Uninformed and informed consent - from a patients point of view (2.48)

Using Teach Back technique may be a good idea to determine if our consent is informed
Teach back - technique for clear communication regardless of health literacy (9.13)

When to use a written consent form - By Dental protection (podcast) 9 minutes
AHPRA Dental code of conduct

"documenting consent appropriately, including considering the need for written consent for procedures which may result in serious injury or death." from Ahpra Dental code of conduct.

 

 

Being with the patient (and not in our mind) exercise
Ask the group to look around your room- take them on a Zoom tour and ask them to notice all the orange and red things.
Then bring them back and ask then to tell you everything blue they saw.
The object is to point out that we are most aware of what we have already decided to look for.
Sometimes that is really appropriate but sometimes it hinders us seeing other things that will be important.

Can we develop the gift of Affirmations? Building rapport without deception
PURPOSE: We know that affirmations to patients and anyone we interact with are exceptionally meaningful ways of connecting and have actually been shown as one of the most significant factors in inspiring people to change. Whether this comes easy or hard to us may be related to the 'norms' of our family of origin.
HISTORY: I have found some students repeat an affirmation that was suggested to them but they don't understand that without the context this isn't helpful for communication. Affirmation-context=platitude This activity helps students increase their affirmation vocabulary and to verbalise affirmations.
Do the "what we notice" exercise. Ask the students to write down something they enjoy doing (or have done), that they get joy out of and that they consider themselves good at or reasonably good at. By writting it down we want our mind to know that we dont need to put our attention in this exercise, towards what we are going to say. We can be free to listen and be attentive to what our fellow students share. (discuss charismatic people and their ability to exude the feeling that they are totally present with whoever they are talking with)
a) put the students in breakout groups of 3
b) Ask the students to talk for 30 seconds about the activity that they wrote down.
c) After they have finished talking, tell the students that the next part of the exercise is that they will introduce one of their fellow students to the other student in their group and will include a "characteristic" or strength that they noticed or thought of within that person, as part of the introduction. (30 sec) Each person must have someone speak about them so you need to go around the group so people dont introduce each other.
Email students the series of strength cards (see attached) because sometimes we dont have a good vocab.
d) back in the bigger group. Ask people to pick one of 3 things (hold up fingers to show)
1. Your affirmation resonated with you
2. Affirmation didnt really reasonate with you but you can understand why the other person said it
3. You thought what was said was totally off track

Use this as a discussion; How did it feel when it was right/wrong neutral? How can you tell?
Why are affirmations so productive in relation froming/ change? How we each love the feeling of being "know"? How others can remind us of the better parts that make up "me".

Learning that "Health is not just what we do; but what has been done to us."
PURPOSE: Helping develop compassion/empathy for our patients.
HISTORY: We often dump our students in the discordant world of student/public healthcare. They start by telling patients that they are in a student clinic so they have to have all this stuff done to them or they cant come - and then we say "but we are patient centred". They hear that dental health is a behavioral disease; that people in public health don't appreciate dental care as much because they are not paying for it etc etc. The purpose of this exercise is to try and bring student awareness to the fact that their own dental health is not only of their own making but is because of the influences outside their control.
a) groups of 3 or 4 - one person in the group discusses their teeth cleaning and mouth health routine in as much detail as they can; the others in the group can ask them questions about it so they really understand the what; why, when and how of that person. Probably write it in quick notes so you get it clear
b) The members of the group should list the factors that have contributed to that particular care routine.
c) bring them back to discuss and then point out AFTER they have come back, the influence of family or others e.g. who taught you to brush, who supervised you, what was the family norm for doing that (or any healthcare)- why did you do that - characteristics of person and of the family etc.
d) back in the groups and ask each person to discuss these for their own mouth health. e) whole group - insights and summary.

Dealing with difficult situations exercise -with emotional awareness
PURPOSE: To help students name an emotion (increase vocab) ; gain some awareness of our own reaction to certain emotions and then feeling more comfortable in reflecting others emotions in a non-judgemental way.
HISTORY: I asked the students what they imagined they would feel if they broke a file doing endo. They all said they would feel "bad" so I thought it would be helpful to increase normal vocab. They also said that they could tell what a patient was feeling but patients couldn't tell what they were feeling! Interesting! Students also found reflecting for a complaining patient was difficult. (Aren't we all problem solvers!!)
a) groups of 6 or more - the aim is to hear as many different examples as possible so a smaller group may not result in this.
b) email out the emotion cards and ask people to pick one or two emotions that they find hard to deal with in other people and one emotion that they find hard to deal with or that they dislike in themselves. (you will need to note these to do the next activity - or reask people)
c) Get each of the group to then do a reflection on another person - for the emotion that they don't like in themselves or another - it doesn't really matter) d) this would lead well into a discussion of what to say when things go wrong; what to say when someone complains.
NOTE to self: being aware of what emotions you find uncomfortable in others is really important in your strategies for complaint management.

Endodontic communication hints

WHAT TO SAY IF A ENDODONTIC MISHAP OCCURS

Informing a patient of a procedural accident does not immunize the clinician from malpractice litigation. It does maintain rapport with the patient, make any such litigation less likely, and make negligence more difficult to establish. Simple gestures like calling your patients the night of treatment will build your practice and are part of being a caring professional.





Role play because you don't want the first time you practice a new skill to be in front of a patient.


Talking money:
Cost Complainer: - Remember you are not trying to talk the patients into something.

Are we projecting our own bias, convictions on others?
Separate or recognize your own convictions about money
1. don't make assumptions about what people can or cant afford
2. Simplify your fees, make it easy to remember and say out loud
3. People don't buy on price alone and don't reject on price alone
4. Don't discount based on fear
5. Don't feel bad - it is an option for the patient to choose
6. Recognize your upper mental $ limit

----------------------------