Cindy L. Adams1 and Suzanne M. Kurtz2
1Department of Veterinary & Clinical Sciences, University of Calgary, Canada
2College of Veterinary Medicine, Washington State University, USA
The overarching purpose of this chapter is to improve communication education in veterinary medicine, from the beginning of veterinary school and throughout a career. To accomplish this, we offer a practical guide to teaching communication effectively. We include reasons to invest in communication skills teaching programs, what we are trying to teach, and methods to develop learners’ communication skills that enable learners to use these skills in practice and continue to develop them throughout their careers. We conclude by advocating for clinical communication programs and offering several suggestions to build a program that extends the impact of the dedicated communication course.
The first steps in teaching (and learning) communication effectively are to gain an evidence-based understanding of why we teach communication and to determine just what it is we are trying to teach. The reason we have added “and learning” is to underscore the fact that learners need this orientation and understanding as much as intructors do.
An extensive body of research developed over the past 45 years in human medicine, and more recently in veterinary medicine, indicates that improving clinical communication in specific ways leads to the benefits summarized in Box 23.1.
These findings confirm that communication is an influential clinical skill in veterinary (and human) medicine that deserves to be taught and learned with the same rigor as medical technical knowledge, clinical reasoning, physical examination, and other procedural skills. The clinical outcomes that depend on communication are too central to leave the development of skilled communication to chance (Cake et al., 2016). The research evidence is too strong to refute. For an in-depth review of the studies substantiating the benefits in Box 23.1, see Silverman et al., (2013) in relation to human medicine and Adams and Kurtz (2017) for veterinary medicine.
In keeping with the evidence base, the broad learning goals of clinical communication are as follows:
- Ensure increased accuracy, efficiency, and supportiveness of client interaction.
- Enhance client and veterinarian satisfaction.
- Improve outcomes of veterinary care.
- Promote collaboration and partnership (relationship-centered care).
- Enhance coordination of care (between healthcare providers, patients, clients, families, and production animal workers).
The goal of communication education is not merely to improve knowledge and understanding of communication, but to improve clinical communication skills to a professional level of competence. Professional competence implies heightened awareness, greater ability to reflect and articulate with precision, heightened intentionality, and more consistent performance across all situations. Moreover, professional competence is evidence based. These goals of communication training remain the same across all levels of medical education. At more senior levels, deeper mastery of skills and development of attitudes or capacities is expected. Contexts and problems become more complex as learners advance, but the goals of training remain constant.
A second rationale for communication education is that the veterinary profession, recognizing the significance of the contribution that communication makes to clinical practice, is making communication a required part of the curriculum. Many key studies and reports emphasized the need for a focus on the development of veterinary students’ “professional competencies.” Subsequent studies indicated that many veterinary graduates were clinically competent, but lacked the crucial skills, knowledge, and attitudes essential for practice success (Brown and Silverman, 1999; Cron et al., 2000; Chadderdon, King, and Lloyd, 2001; Lloyd and Walsh, 2002). These findings have played a significant role in terms of communication training in veterinary education.
Responding to these reports and recent research, professional organizations and veterinary medical education councils have acknowledged and taken on communication training as an essential component of the curriculum. For example, the American Veterinary Medical Association Council on Education (AVMA, 2012) lists client communication as an essential outcome of the Doctor of Veterinary Medicine (DVM) program, and states that graduating students must be able to demonstrate communication competence (AVMA, 2012). Veterinary educators in many countries have begun to include communication teaching within the veterinary curriculum (see, e.g., Heath, 1996; Radford et al., 2006; Adams and Ladner, 2004; Adams and Kurtz, 2006; Kurtz, 2006; Shaw and Ihle, 2006; Mills, 2006; Gray et al., 2006; Chun et al., 2009; Baillie, Pierce, and May, 2010; Hecker, Adams, and Coe, 2012; Artemiou et al., 2014; Everitt et al., 2013; Hafen et al., 2013; Hodgson, Pelzer, and Inzana, 2013; McArthur and Fitzgerald, 2013; McDermott et al., 2015; Mossop et al., 2015), and clients and veterinarians have recognized the importance of communication (Blach, 2009; Walsh, Klosterman, and Kass, 2009; Mellanby et al., 2011).
Defining What We Are Trying to Teach
Given that communication is an essential clinical skill in veterinary medicine, how do we define effective clinical communication, and how do we decide what to teach?
A Skills-Based Approach
Whether enhancing our own clinical communication skills, assisting others, or designing communication education programs, how we think about communication significantly influences how we teach communication and what we do with it in practice. Consequently, it is helpful in defining what to teach and learn to distinguish between three types of clinical communication skills:
- Content skills: what you communicate, for example the substance of your questions and responses, the information you gather and give, the issues and treatments you discuss.
- Process skills: how you communicate, for example how you go about discovering the history or providing information, structure interactions, ask and respond to questions, relate to clients and patients, use nonverbal skills, involve clients in decision-making.
- Perceptual skills: what you are thinking and feeling, for example your internal decision-making, clinical-reasoning, and problem-solving skills; your attitudes, values, and personal capacities for compassion, mindfulness, integrity, respect, flexibility; your awareness of feelings and thoughts you have about the patient, the client, and the problems or other issues that may be concerning them; what you do with your own feelings and those of your clients; awareness of your self-concept and confidence and of your assumptions, biases, and distractions.
Content, process, and perceptual skills are highly interdependent – a weakness or strength in one set of skills translates into a weakness or strength in all. We must give attention to all three when trying to teach and learn effective clinical communication (Riccardi and Kurtz, 1983; Kurtz, Silverman, and Draper, 2005).
Three approaches to communication teaching and learning are prevalent: skills based, issues based, and attitude based. We deliberately encourage taking a predominantly skills-based approach rather than an issues-based approach. The skills-based approach gives primary emphasis to the development of learners’ communication process skills, since these tend to be least emphasized in other parts of the curriculum, and secondary attention to content and perceptual skills, since they are taken up elsewhere. The issues-based approach organizes coursework and learning around issues such as end of life, ethics, cost discussions, informed consent, communicating treatment risks and benefits, communicating with children, cultural issues, etc. These issues are important, but the focus needs to be on the skills required to deal with these issues; once individuals understand and develop competence in applying the skills, communication issues and challenges can be much more readily tackled. There is no need to invent a new set of skills for each issue. Instead, we need to develop the learners’ core communication skills, along with the awareness that some skills will need to be used with greater intention, intensity, and awareness. We need to deepen understanding of these core skills and enhance the level of competence with which we apply them. For a detailed example of how to apply the skills differentially to cultural issues, see Kurtz and Adams (2009).
The attitudes-based approach organizes teaching around learners’ attitudes, and biases, by developing the values and capacities that influence communication. Skilled communication without the commensurate development of values quickly becomes manipulation. On the other hand, developing values and capacities without the skills to demonstrate them is also insufficient.
Only the skills-based approach provides the communication skills that enable learners to deal with issues and to put capacities, values, beliefs, and intentions into practice. The core skills that we describe represent the foundation for effective clinical communication in all circumstances.
What It Takes to Learn (and Teach) Skills, Change Behavior and Master Skills
Seven elements are necessary to change behavior and master any skill set:
- Systematic delineation and definition of the evidence-based skills to be learned.
- Observation and assessment of learners performing the skills (live and/or on video, but for communication skills preferably with some video or at least audio recording of the interaction).
- Well-intentioned, detailed, descriptive feedback (guided reflection, coaching, peer feedback, and self-assessment).
- Practice and rehearsal of skills in various veterinary contexts.
- Planned reiteration (a helical, reiterative teaching/learning model rather than a linear, once-and-done model; this includes applying the skills in increasingly complex situations or contexts over time).
- Interactive small group or one-to-one experiential teaching/learning format.
- Performance-based assessment strategies.
Finding or making opportunities to bring all seven elements into play is a primary challenge for anyone who wants to enhance clinical communication skills in veterinary medicine. This is true for learners at any level: individual veterinarians who want to improve their personal clinical communication skills or the skills of their practice group; coaches and preceptors, faculty members, or program directors involved in coursework or clinical rotations, residency training, or continuing education programs or acting as role models; veterinary hospital or other organizational administrators. How these challenges are met depends on what can be made possible in each of those contexts, both through course/program design and via the efforts of individual teachers. (For detailed explanations and review of research evidence regarding these elements, see Kurtz, Silverman, and Draper, 2005.)
Deciding How to Teach and Learn Clinical Communication: The Elements Elaborated
We use the essential elements listed on the previous page as a way to organize the discussion of how to structure and teach clinical communication.
Systematic Delineation and Definition of Communication Skills
Placing the delineation of specific skills at the top of the list of essential elements is not accidental. All the other components are dependent on that first basic element.
Specific Communication Process Skills Worth Teaching and Learning
We know that knowledge about the clinical communication skills that learners are trying to enhance and the research behind those skills is useful and important. Yet, as with other clinical skills, knowledge does not translate directly into either competence (can you do it?) or performance (do you [choose to] do it in practice?). Nor does simply watching the experts. I can read a lot of books on tennis and watch a lot of excellent tennis and still improve my skills very little if I never really focus on developing them. Yet still, just what are the specific communication skills that enable everything else?
While several skills models and frameworks are available, one of the most comprehensive, applicable, and utilized in veterinary medicine is the Calgary–Cambridge Communication Process Guide and its companion Content Guide, known collectively as the Calgary–Cambridge Guides (Kurtz et al., 2003; Kurtz, Silverman, and Draper, 2005; Silverman, Kurtz and Draper, 2013; Adams and Kurtz, 2017). Evolving since the 1980s, the Calgary–Cambridge Process Guide includes 58 highly evidence-based communication process skills, plus another 15 process and content skills related to common focuses of explanation and planning. Validated by a large body of research, the communication skills in the guides are applicable to routine and complex medical situations, to an array of issues (finances, ethics, end of life) in veterinary medicine, and across all contexts (e.g., small and large animal practice). The guides were originally developed in faculties of medicine at the University of Calgary (Canada) and, in a later collaboration, Cambridge University (UK). First published in 1998 (Kurtz, Silverman, and Draper; Silverman, Kurtz, and Draper, 1998) the guides have continued to evolve in subsequent editions of these two companion books and are used world-wide in human medicine. Initially adapted for veterinary medicine in 2000, the use of the guides in veterinary contexts has also expanded (Adams, 2000; Adams and Ladner, 2004; Adams and Kurtz, 2006; Gray et al., 2006; Latham and Morris, 2007; Hecker, Adams, and Coe, 2012).
Taken together, the skills in the guides represent the state of the evidence regarding the communication skills that make a difference to clinical practice outcomes. These are the skills that research and experience indicate are necessary in order to achieve the benefits and outcomes listed in Box 23.1. Corresponding directly to what transpires in veterinary consultations, Figure 23.1 depicts the organizational framework for the Calgary–Cambridge Process Guide. See total guide in Adams and Kurtz (2017).
The guides have three broad aims: to help learners and practitioners conceptualize and structure their communication learning and practice; to summarize the clinical communication literature in an accessible way; and to assist clinical teachers and communication program directors in their efforts to establish training programs for both learners and those facilitating the learning, whether working in veterinary schools, residency, or continuing education. The guides are the backbone of communication program design, teaching, learning, feedback, assessment, and coaching, whether in an educational setting or in practice. Providing a common foundation for communication teaching and learning at all levels, the Calgary–Cambridge Guides are applicable to all types of practice, and to everyone from veterinary students to veterinarians who have years of experience.
First Principles of Effective Communication (and Teaching)
Thinking in terms of first principles that characterize effective communication offers another useful resource for teaching and learning communication skills. The principles help us keep in mind what we are trying to do, which process skills to bring into play (Kurtz, 1989; Dance and Larson, 1972; Dance, 1967), and where the skills in the Calgary–Cambridge Guides are needed to put the principles into practice. Importantly, these same principles also characterize effective teaching.
Effective communication (or teaching):
- Ensures interaction not just transmission. Only giving information or telling someone what to do is insufficient; accuracy, efficiency, and relationship require two-way conversation, feedback, questions and responses from both client and clinician.
- Reduces unnecessary uncertainty. Uncertainty distracts attention and interferes with accuracy, efficiency, and relationship; for example, we can reduce uncertainty about the patient’s problems and anticipated outcomes, the client’s expectations for a visit, the clinician’s expectations, the structure of the interview, how the team works, and so on.
- Requires planning, thinking in terms of outcomes. Effectiveness can only be determined in the context of the particular needs and outcomes toward which the clinician and the client are working and consideration of the patient’s needs at any given moment. If I am angry and want to vent that anger, then I communicate in one way, but if I want to get at the misunderstanding that caused the anger, then to be effective I must communicate in an entirely different way.
- Demonstrates dynamism. This principle includes engaging with the patient/client, and being present, responsive, and flexible. Clinicians need to develop a repertoire of skills that allow different approaches with different individuals, or even with the same individual as circumstances change.
- Follows a helical rather than a linear model. Saying something once is not enough; repetition and feedback are essential. Each reiteration moves us up the spiral to a higher level of understanding. Similarly, the helix is an excellent learning/teaching model. Developing communication skills and maintaining competence require reiteration as skills are deepened and applied in different contexts.
These principles are a useful self-assessment tool for learners (and teachers). Ask yourself what you did to ensure that each of the principles was in play during a given consultation (or teaching session). The first principles of effective communication also serve as a useful reference point – whenever in doubt about what skills would be most effective, go back to first principles to help you decide.
Communication process skills are the primary focus of teaching and learning clinical communication. However, what about the content of the consultation?
Ideas for Linking Content with Communication Process Skills
Although communication courses do not focus primarily on the medical content of the consultation, you cannot teach or learn process skills without keeping in mind what learners are trying to communicate about in veterinary contexts, as well as the interdependence between process and content skills. So content becomes a secondary focus of communication teaching and learning. A “content guide” that helps learners to structure what they are saying (or trying to say) is a useful resource to incorporate. One such guide forms the second part of the Calgary–Cambridge Guides. This content guide (see Table 23.1) works directly with the Calgary–Cambridge Process Guide. Because the two guides are closely aligned, they reinforce each other and encourage integration of content with process skills.
Table 23.1 Calgary–Cambridge Content Guide – Veterinary Medicine
|Patient and/or flock, herd problem list|
|Present history – exploration of patient/flock/herd problems|
|Veterinary medical perspective|
|Sequence of events|
|Analysis of signs|
|Relevant systems review|
|Ideas and beliefs|
|Effects on life (of animal and client)|
|Background information – context|
|Past medical history|
|Environment and lifestyle|
|Current medications, adverse drug reactions, and allergies|
|Genetic and familial background|
|Review of systems|
|Differential diagnosis – hypotheses (veterinarian’s and client’s)|
|Veterinarian’s plan of management|
|Explanation and planning with client|
|What the client has been told|
|Plan of action negotiated|
Source: Adams and Kurtz, 2017, pp. 35–36. Adapted for veterinary medicine from Kurtz et al., 2003, pp. 802–809.
While the Calgary–Cambridge Content Guide offers a useful way to structure any given veterinary consultation from start to finish, learners frequently require additional direction in order to collect pertinent details of history from the client regarding the patient. Recognizing this fact led to the development of four species-specific history-taking “pyramids” at the University of Calgary that learners there use from Year 1 to the end of veterinary school (see Wilson et al., in Adams and Kurtz, 2017). Figure 23.2 offers an example of one of the pyramids.
Like the Calgary–Cambridge Guides, the pyramids are based on the premise that the best patient care can be delivered if learners (and ultimately veterinarians) can identify not just the chief complaint, but all of the patient’s problems or issues as well as the client’s perspectives. Developed using the same template, the other species-specific pyramids reflect pertinent content that needs to be collected relative to those species. For instance, with production animals, herd considerations versus individual animal considerations are needed. Included in the communication course, the pyramids then become a means for integrating aspects of communication with the rest of the veterinary curriculum. The pyramids help ensure consistency between what students learn in small-group simulations and what they do in real-life settings.
Ideas for Linking Perceptual Skills with Communication Process and Content Skills
The communication course also offers opportunities to underscore the interdependent relationship between perceptual skills and communication process and content skills. For example, we use the straightforward clinical method map in Figure 23.3 (Bryan and Cary, 2010) to help learners conceptualize how their communication with any given client fits into the sequential pattern of the clinical method.
Asking students to identify points on the map where communication process and content skills affect what students are doing with clients and animals helps learners visualize just how frequently veterinarians rely on communication skills during clinical practice. Asking learners then to discuss the points on the map at which communication process and content skills have an impact on their clinical reasoning and what that impact is – or to consider how what they are thinking at any given point affects how they are communicating with clients or patients – helps students to realize how these skills influence each other (Kurtz, 2016):
- Clinical reasoning consists of the thought processes in which you engage as you collect information and opinions from various sources (e.g., the patient, the client, and others; physical examination; diagnostic tests; veterinary staff and colleagues; the medical record) and synthesize that information with your knowledge and experience to generate hypotheses, differentials, diagnoses, and action/treatment plans. These perceptual skills occur at the intrapersonal level of communication.
- Clinical communication skills and capacities
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