Micro-coding of communication behaviours in the OSCE. Dr Peter Leadbetter

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1 Micro-coding of communication behaviours in the OSCE Dr Peter Leadbetter

2 My background Not an experienced researcher but experienced in examining the micro behaviours of medical students/junior doctors (specifically how they respond to patient/sp emotion) Your background?

3 Setting the scene. Part of a recently completed PhD (University of Liverpool) Over 500 medical students, 150 patients, 25 clinics Cross sectional & longitudinal studies Two broad aims 1. examine the relationship between medical students attachment orientation & their clinical communication skills (OSCE & primary care) 2. examine the transfer of medical students clinical communication skills longitudinally (OSCE to primary care)

4 Why communication skills? Research linked effective patient-clinician communication to a variety of positive outcomes Delivery of high quality medical care Patient & physician satisfaction Increased understanding of health concerns and treatment options Treatment adherence Health outcomes for the clinical Fewer malpractice claims (Deveugele, 2005; Haidet, 2001; Street, 2005).

5 Communication skills Core competency of Medical degree Universally assessed via the OSCE in the UK Largely taught in simulated encounters Value in assessing if these skills transfer to real patient encounters in primary care (especially emotive aspects of clinical communication) Surprisingly few longitudinal studies exploring medical students clinical communication

6 Aim Examine if medical students communication skills transfer from the simulated setting (OSCE) to the real setting (Primary care)? Specifically medical student responses to patient emotion and distress within these settings

7 Design/methods A longitudinal cohort study medical students (n= 37) videoed in a communication station in their final OSCE (4 th year) 2. Same cohort videoed in the following year (5 th year) consulting patients in Primary care 2 to 5 patient consultations per students (n=138) 3. All videos coded with Verona Coding Scheme (how they respond to emotional cues) University; NHS central & PCT ethical approval

8 Coding of videos: Verona consensus coding scheme (Del Piccolo et al, 2006) Detects & quantifies number of patient emotional cues/concerns with associated number of responses 1. Detect patient cues of worry, distress & negative emotion 2. Code student responses into 2 broad categories Provide space: responses that facilitate further discussion (e.g. empathy, acknowledgement, pauses) Reduce space: responses that block further discussion (e.g. changing topic, ignoring, interrupting) 3. Expressed as a proportion (%) of provide or reduce space responses

9 Descriptive results Mean St Dev Number of cues elicited per consultation (OSCE) Percentage of provide space responses (OSCE) Number of cues elicited per consultation (Primary care) Percentage of provide space responses (Primary care)

10 Results Inter-rater reliability (cues: 0.83)(responses 0.81) Correlation analysis Significant positive correlation (large effect size) between provide space responses in the OSCE (4 th year) & primary care (5 th year) (r=0.64) Students who explored emotive cues in the OSCE were also likely to explore emotive cues in primary care

11 Further results A significant positive correlation between OSCE communication examiner ratings & provide space responses in the OSCE (medium effect size) A significant positive correlation between OSCE communication examiner ratings & provide space responses in primary care (small effect size)

12 Conclusion Medical students OSCE communication examiner ratings reflective of medical students emotional responsiveness in the OSCE & primary care Support for the 4 th year communication OSCE as a valid measure of medical student s responsiveness to patient emotion in primary care Provides longitudinal support for the teaching & assessment of communication skills at UoL Huge scope for further exploration with other health professionals at Edge Hill University

13 Limitations Provide space responses taken from one station Video only directed at student No data collected on students who failed Small sample (however part of a larger investigation)

14 Why is it important to respond to patient emotion? Is it always required in consultations?

15 Micro-coding of communication behaviour Why Overview of coding tools Any familiar? Issues with?

16 Micro-coding of communication behaviour (handout) Definition of patient cues of emotional distress? Frequency of patient cues of emotional distress in consultations? Types of patient cues to emotional distress? The benefits of responding to cues of emotional distress? Appropriateness of doctors responses to cues of emotional distress in the literature? Actual responses to cues of emotional distress? Reasons for not responding to cues of emotional distress?

17 Coding of videos: Verona consensus coding scheme (Del Piccolo et al, 2006) Detects & quantifies number of patient emotional cues/concerns with associated number of responses 1. Detect patient cues of worry, distress & negative emotion 2. Code student responses into 2 broad categories Provide space: responses that facilitate further discussion (e.g. empathy, acknowledgement, pauses) Reduce space: responses that block further discussion (e.g. changing topic, ignoring, interrupting) 3. Expressed as a proportion (%) of provide or reduce space responses

18 Coding of videos: Verona consensus coding scheme (Del Piccolo et al, 2006) Cue: A verbal or non-verbal hint that suggests an underlying unpleasant emotion and would need a clarification from the health provider (Zimmermann et al, 2011: 141). Examples include I feel rotten inside Concern: A clear and unambiguous expression of an unpleasant current or recent emotion where the emotion is explicitly verbalised, with or without a stated issue of importance for the patient (Zimmermann et al, 2011: 141). Examples include I am depressed and I am worried about my headaches. Distinction between a cue and concern relates to its explicitness. A cue is usually an indirect hint or clue from a patient, while a concern is explicitly verbalised by patients. Nonetheless, both cues and concerns have negative emotional content that require further exploration and/or acknowledgement.

19 Coding of videos: Verona consensus coding scheme (Del Piccolo et al, 2006) Responses Non-explicit OR Explicit Refers to whether the response of the health provider maintains the wording or the key elements of the cue/concern it refers to 17 categories of responses Main distinction Provide space: responses that facilitate further discussion (e.g. empathy, acknowledgement, pauses) Reduce space: responses that block further discussion (e.g. changing topic, ignoring, interrupting) Expressed as a proportion (%) of provide or reduce space responses

20 Focus iii software What does a coding script look like (example)

21 Practical examples OSCE scoring Respond to emotion Identify emotional cues/concerns (how many?) How did they respond generally (provide or reduce?) Discrepancies between examiner ratings & VR-CoDES?

22 Relevant issues micro-coding

23 Relevant issues micro-coding Assumes provide space the most adequate/patient-centred response (may not reflect patient views) Responses influenced by perceived health status of patient Interpretation/subjectivity Range of different coding schemes with varying definitions of cues/concerns Time consuming (17 categories) Inter-rater reliability at individual code-level Loss of potentially important information not captured if collapse categories together (depth of engagement, different skills) If cues & concerns are combined then different responses required Focus on negative emotion Focus on verbal Only last cue in speech turn coded

24 Strengths of coding microbehaviours?

25 Strengths of coding microbehaviours? High inter-rater reliability & validity (consensus definitions & detailed training & procedures) Enabled clinical communication to be studied as it actually occurs in natural settings (data checking & re-coding) Comparative research (forefront methodologically) Focus on interactional processes (bi or multi-directional) Reliability as typically several cues in each consultation Timing of any research (Francis Report) Linked to clinical communication OSCE results at UoL Video feedback for training purposes

26 Future research avenues Relationship between patient, & health professional initiated cues Explore specific individual categories of responses (especially categories that require more emotional engagement) Cross contexts (e.g. oncology & psychiatry) Examine what patients perceive as most appropriate across settings

27 Practical implications

28 Practical implications Generate information beyond the OSCE on it s own (specific direct comparison of micro-behaviours) Modifiable & adaptable Formative OSCE video feedback to increase cue recognition and responses (practice with feedback) Video feedback to identify struggling students (early) and identify good practice If correlates with OSCE communication ratings then combined with small-group feedback & role play Theoretically and practically fits with PBL sessions to assist students in constructing won experience & learning Part of a multi-dimensional approach

29 Conclusion & queries Research to allow for more in-depth understanding of medical students micro-behaviours in a variety of contexts Longitudinal research on medical students clinical communication across contexts is required The OSCE may be able to adequately differentiate between medical students who respond to emotion and those who do not (more research required) Dr Peter Leadbetter leadbetp@edgehill.ac.uk

30 References Del Piccolo, L., de Haes, H., Heaven, C., Jansen, J., Verheul, W., Bensing, J., et al. (2011). Development of the Verona coding definitions of emotional sequences to code health providers responses (VR-CoDES-P) to patient cues and concerns. Patient Education and Counseling, 82(2), Deveugele, M., Derese, A., De Maesschalck, S., Willems, S., Van Driel, M., & De Maeseneer, J. (2005). Teaching communication skills to medical students, a challenge in the curriculum? Patient Education and Counseling, 58(3), Haidet P, Dains JE, Paterniti DA, Chang T, Tseng E, Rogers JC. Medical students' attitudes toward patient-centred care and standardized patients' perceptions of humanism: a link between attitudes and outcomes. Academic Med 2001;76 (Suppl.):S42 S44. Street, R. L., Jr., Gordon, H. S., Ward, M. M., Krupat, E., & Kravitz, R. L. (2005). Patient participation in medical consultations: Why some patients are more involved than others. Medical Care, 43(10), Zimmermann, C., Del Piccolo, L., Bensing, J., Bergvik, S., De Haes, H., Eide, H., et al. (2011). Coding patient emotional cues and concerns in medical consultations: The Verona coding definitions of emotional sequences (VR- CoDES). Patient Education and Counseling, 82(2),