| As teachers, we should carefully consider the best ways to help students file and retrieve information. Teaching communication skills is inherently challenging for a number of reasons, including the sometimes inaccurate preconceptions of learners and the complexity of the subject. These skills are essential for conducting effective client interviews, one of the most common procedures among veterinarians in clinical practice.
In their text Guided Instruction, Fisher and Frey, both PhDs and professors of
Educational Leadership at San Diego State University, discuss using scaffolds
to facilitate student learning. They
suggest, “Teachers need to chunk information in ways that are consistent with
working memory and long-term transfer. One of the ways to do this is through
work with schemas, or mental structures that represent content.”
The Calgary-Cambridge Guide (CCG) has served as one such schema in a number of communication skills training programs in both human and veterinary medical student education. This guide delineates and structures more than seventy individual communication skills substantiated by research or theoretical application in the human medical field. Although the CCG offers a number of benefits in teaching communication skills, it also has limitations. As this guide was developed based on interactions between physicians and their patients, it does not address unique aspects of the veterinary-client-patient relationship. The CCG provides guidance on the process of communication, but does not include suggested content. For example, the CCG suggests learners should use open-ended questions when collecting a medical history, but doesn’t provide guidance on what information should be gathered by the veterinarian. Veterinary students must learn to investigate and deliver specific content in the client interview, including identifying client concerns, exploring social and lifestyle aspects of the history, screening key body systems, ensuring informed consent, and discussing finances. The artificial separation of content and process when teaching client interview skills can be confusing for veterinary students, who must learn both process and content skills so these can be deployed simultaneously in the client interview. Finally, some veterinary students, and even experienced veterinarians, are overwhelmed when asked to consider more than seventy specific skills. As a result, most training programs actually focus on only a subset of skills included in the CCG. In hopes of taking advantage of significant benefits of the CCG while addressing opportunities for improvement in teaching communication and client interview skills to veterinary students, more than six years ago we developed a teaching framework based on the mnemonic WISE COACH. This instructional strategy was designed to delineate key process and content skills while helping students improve their memory of important skills related to communication and conducting effective client interviews. WISE COACH Conducting Effective Client Interviews The WISE COACH acronym reflects a relationship where the veterinarian is an experienced, knowledgeable guide who educates and encourages clients, respecting their individuality while seeking the best outcome for the patient. Welcome the client and patient · Review information and adjust emotional tone to situation before entry · Introduce self with good eye contact and thank client for their patience prn · Clarify client and patient names and use them throughout the interview · Greet and compliment the patient · Establish equal eye level with client (ideally sitting) and avoid barriers · Ask non-medical question(s) to connect on a personal level · Explain the process and mention that cost will be discussed · Demonstrate warmth, respect, and interest
· Begin with and incorporate open-ended questions · Use attentive and reflective listening without interruption · Solicit for other client concerns and, if necessary, establish an agenda · Be aware of your and the client’s non-verbal signals throughout the interview · Investigate signs, severity, frequency, progression, palliation, etc. · Investigate client goals, beliefs, feelings, and concerns · Ensure note taking, whether typed or written, is minimally intrusive
· Summarize key information and client concerns · Express authentic empathy and support throughout the interview · When appropriate, compliment the client · Signpost steps and transitions – “Next I’d like to….”
· Ask about lifestyle · Ask about past history, preventive care, diet, allergies, and behavior · Ask about current medications and supplements · Perform systems review
· Approach and handle the patient gently and safely · Build rapport by commenting on and talking to patient · Narrate key elements of the physical exam
· Share findings with confidence, clarity, and sensitivity · Determine prior client knowledge related to findings · Describe impact of findings on patient well-being · Share information in manageable chunks and check client understanding · Avoid or define medical terms · Use visual methods to convey information
· Suggest an optimal plan or, if that is unclear, describe options · Take client’s lifestyle, perspective, beliefs, and abilities into consideration · Explain benefits and possible risks to patient, including risk of NOT proceeding · Discuss patient comfort · Confidently discuss costs and payment options before seeking approval · Notice and respond to non-verbal signals of concern
· Check client’s understanding, feelings, and acceptance of the plan · Help the client feel in control – avoid pressuring · Offer alternatives as needed · Find common ground – “We both want…” · Obtain and document informed consent
· Recap the plan and verify agreement · Set realistic expectations for care and communication · Provide written and/or on-line resources · Ask if all client concerns have been addressed · If appropriate, schedule procedure or follow up
· Act as patient advocate while respecting client perspective ·
Build
positive relationship with both client and patient throughout process The WISE COACH model is based on the Calgary-Cambridge Skills Guide, a comprehensive collection of evidence-based communication process skills developed for training in the human medical field. Your suggestions for improvement of the WISE COACH model are welcome. Please contact jclark@ucdavis.edu. This educational framework, which has been revised and refined several times, has been well accepted by our students and helpful in their development of effective communication and client interview skills. In a 2015 survey, our teaching hospital house officers and faculty were asked to assess the entry-level competency in 14 different domains of students beginning their fourth-year clinical rotations. Students’ communication skills received the highest ratings among the 14 domain areas. Additionally, several large veterinary employers have commented on the well-developed communication skills of our graduates. The largest provider of veterinary emergency services in the United Kingdom, VetsNow, developed a successful communication skills training program for their organization based on the WISE COACH model. Preliminary evaluation of the utility of the framework in training U.S. veterinarians in general practice has also been encouraging. In summary, WISE COACH is one possible teaching framework that may help veterinary student and other learners develop the complex skills required for successful communication in a client interview setting. Research evaluating this model relative to other instructional approaches would be helpful.
For good reason, the CCG is deeply entrenched in veterinary communication instruction. Kurtz and Silverman discussed the benefits of this model in medical teaching many years ago (Med Educ 1996). Nonetheless, there are opportunities to improve our approach to teaching in this area by seeking approaches that may increase student engagement, understanding, and retention. Fisher and Frey recommend creating systematic and intentional scaffolds to facilitate student understanding rather than leaving them alone to discover information independently. The term scaffold, as applied to learning situations, comes from Wood, Bruner, and Ross (1976), who define it as a process "that enables a child or novice to solve a task or achieve a goal that would be beyond his unassisted efforts." Research has demonstrated that the way we encode information when we first study affects memory retention. The WISE COACH scaffold combines important process and content skills in a simple mnemonic designed to give students a helpful way to take encode information so that it will be easier to remember (retrieve) in lab or practice settings. The model also includes practical reminders for conducting effective client interviews identified by a team of experienced veterinarians from small and large animal practice. Other organizations may have developed other helpful approaches to teaching communication and client interview skills. Because the CCG was developed in the human medical field, all instructors must consider its applicability in veterinary practice and how best to apply and adapt this model in our field. This poster outlines a new model that might benefit other educators and students. Additionally, it provides a forum for productive dialogue about our approach to teaching communication and client interview skills. Author: Jim Clark, DVM, MBA Professional Skills Course Leader, UC Davis School of Veterinary Medicine Co-Founder Pet Emergency & Specialty Centers jclark@ucdavis.edu Cell 415-328-0586 |