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Development, teaching and evaluation of a consultation structure model for use in


veterinary education.

Alan Radford *, Paula Stockley, Jonathan Silverman, Sue Kaney, Ian Taylor, Rob Turner
and Carol Gray ** .

Author information.

* Corresponding author. Alan Radford, BSc, BVSc, PhD, is a research scientist and an
original coordinator of communications skills development and training at University of
Liverpool Veterinary Teaching Hospital, Leahust, Chester High Road, Neston, S. Wirral,
CH64 7TE, UK (alanrad@liverpool.ac.uk).

Paula Stockley, BSc, DPhil, is a research scientist and one of the original coordinators of
communications skills development and training at University of Liverpool Veterinary
Teaching Hospital, Leahust, Chester High Road, Neston, S. Wirral, CH64 7TE, UK
(p.stockley@liverpool.ac.uk).

Jonathan Silverman, FRCGP, Associate Clinical Dean, Clinical Skills Unit, School of
Clinical Medicine, Box 111, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 2SP, UK

Ian Taylor, BSc, MEd, Liverpool Evaluation and Assessment Unit, Centre for Lifelong
Learning, University of Liverpool, 150 Mount Pleasant, Liverpool, L69 3GD, UK.

Rob Turner, BA, Liverpool Evaluation and Assessment Unit, Centre for Lifelong Learning,
University of Liverpool, 150 Mount Pleasant, Liverpool, L69 3GD, UK.

Carol Gray, BVMS, runs the National Unit for the Advancement of Veterinary
Communication Skills (NUVACS) in the UK and is the current programme coordinator for
communications skill straining at the University of Liverpool Veterinary Teaching Hospital,
Leahust, Chester High Road, Neston, S. Wirral, CH64 7TE, UK (cagray@liverpool.ac.uk).

** Names and information for other co-authors are listed below.

Lisa Bush (Veterinary undergraduate), Mark Glyde (University College Dublin), Anne Healy
(University College Dublin), Vicki Dale (University of Glasgow), Sue Kaney (Whiston
Hospital), Christine Magrath (Veterinary Defence Society), Sarah Marshall (Learning and
Teaching Support Network, University of Newcastle), Steve May (Royal Veterinary College,
London), Brian McVey (Small Animal Practitioner, Liverpool), Clare Spencer (Hills Pet
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Nutrition and representing University of Bristol), Ray Sutton (Actor Educators Inc.), John
Tandy (Veterinary Defence Society), Penny Watson (University of Cambridge) and Agnes
Winter (University of Liverpool).
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Introduction
It is now widely accepted that veterinary graduates should enter their profession with high
quality communication skills. However, until recently, this has not been reflected in
undergraduate training. Recently, the Veterinary Faculty at the University of Liverpool, in
collaboration with the profession’s indemnity insurers (Veterinary Defence Society), has
developed one of the first specific communication skills training courses for veterinary
undergraduates (1). For the first three years it has been run, the aim of this course has
been to increase the students’ awareness of the importance of good communication within
the veterinary profession. The course is based on best practice as currently defined in
medical education, making extensive use of actors as simulated clients. As well as
watching acted-out consultations, the students also role-play scenarios designed to expose
them to all aspects of the veterinary consultation (e.g. introductions, history taking, breaking
bad news, fee issues, dealing with anger). Feedback on the role-plays is facilitated by
members of staff.

Evaluation of the first year of this course has been published and has shown it achieves its
aims of increasing the students’ awareness of the importance of good communication with
their clients (1). However, regular facilitators became aware that the student’s learning
experience was very variable, and perhaps more importantly, could not be defined. This
was felt to be a critical block limitation to further development of the course, particularly in
the area of student learning and assessment. It was recognised that one of the major
blocks to further development was the lack of a teaching model suitable for the veterinary
consultation. Such models are routinely used in medical education (2). However, their direct
application to veterinary education is limited because they do not reflect the diversity of
clients with which the veterinary surgeon communicates (e.g. farmers, companion animal
owners), nor do they take into account the two important, and often difficult, areas of
euthanasia and finances.

The aim of this project was to develop a consultation model for veterinary education based
on the Calgary-Cambridge model of the medical consultation. The model was adapted,
recognising both the considerable overlap and also the likely differences between the
veterinary and medical consultation. Subsequently, this model has been used for the
training of communication skills facilitators and undergraduates. Here we present the model
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and provide results of evaluation of its use within the communication skills programme for
veterinary undergraduates at the University of Liverpool.

Methods
Developing a veterinary consultation model.

A two day residential workshop was hosted in August 2002 at Craxton-Wood hotel on the
Wirral. In order to maximise ownership of the workshop results, delegates were invited from
each of the veterinary schools in the UK and Ireland. Most delegates were already involved
in communications skills training at their own institutions, and represented people from all
areas of clinical practice including small animal, equine and farm animal veterinarians. To
further ensure that the products of the workshop were as broadly applicable as possible we
also invited an undergraduate student, a veterinary surgeon in small animal practice, a
representative from industry, and the director of the role-play actors used at Liverpool. The
workshop was co-facilitated by Dr Jonathan Silverman (one of the developers of the
Calgary-Cambridge model) and Dr Sue Kaney (teaching Communications Skills at
Liverpool Medical School). This consensus based approach has been used previously in
medical education (3).
The format of the workshop was briefly as follows. On day one, delegates were first asked
to develop their own structure for the veterinary consultation without referring to existing
published models. This was followed by a brief explanation of the Calgary-Cambridge
model and how it is used in medical education, together with how the model has been
adapted to the paediatric consultation. The Calgary-Cambridge model provides a
comprehensive repertoire of skills that is validated by research and theoretical evidence,
that takes into account the move to a more patient-centred and collaborative style of
consultation, while allowing considerable latitude for individual style and personality (4-6).

Day two of the workshop began with sessions looking at the requirements of the veterinary
consultation in the different areas of small animal, equine and farm animal practice.
Subsequently, in small groups, the Calgary-Cambridge model was adapted to the
Veterinary consultation. This was then formatted and agreed by all the delegates, and
named the guide to the veterinary consultation based on the Calgary - Cambridge model
(GVCCCM).
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The use of the model in the veterinary curriculum.

The Veterinary programme at the University of Liverpool is five years long. The model was
used at Liverpool Veterinary School during the 2003-2004 curriculum as part of the
communication skills training course for third year undergraduates, which is called unit 2. All
facilitators were trained in the details of the model, and how it can be used to structure
feedback in a half-day workshop session with actors. The model was first introduced to the
undergraduates semi-didactically in a half day, large group session, and then used to focus
facilitation, feedback and learning during a three-hour small group session in which role-
play was used to recreate communication scenarios. This learning experience was the
subject of a detailed evaluation, based on the responses of participating students to a
questionnaire completed under supervision, a few days after the event. In addition,
facilitators provided feedback on the impact of the model on teaching and learning
behaviour in small groups.

Results and Discussion


Developing a veterinary consultation model.

The result of the Craxton Wood workshop in the form of the GVCCM is summarised in
figure 1. It is this structure which facilitators use to direct feedback with students. It bears
strong resemblance to the Cambridge-Calgary model on which it was based, highlighting
the similarities between the medical and veterinary consultation, and supporting the use of
best medical practice in this field of veterinary education.

The detailed breakdown of skills used during the consultation is shown in figure 2. This
information is made available to the students on the internet. It is numbered according to
the original Calgary-Cambridge model with added sections identified by the number 0
(Preparation and Observation) or by letters following each number. This approach was
used to further reinforce the origins of this veterinary consultation model. The additions to
this document largely reflect the tripartite nature of the veterinary consultation (owner,
patient and veterinarian). These include the need to

• attends to client’s and animal’s physical comfort (3a),


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• demonstrate understanding of animal’s importance and purpose to the owner

• build a relationship with the client through their animal, by acknowledging and relating to
the animal (30a), and by taking into account the relationship between the client and the
animal when communicating with the client (30b).

Evaluation of the use of the GVCCCM in undergraduate education – the


student’s perspective.

Results of the student evaluation of unit 2 were extremely positive. As in previous


evaluations, and despite some apprehension about the process before they took part, the
students particularly appreciated the opportunity to role-play with actors. The students
benefited from participating in the scenarios, from watching others do so, and from the
subsequent discussions held with the facilitator, actor and fellow students. The focus on
communication served to identify and reinforce positive aspects and highlight areas for
improvement. As a result, students emerged from unit 2 with their confidence raised, feeling
better prepared to cope with future demands.

These small group sessions were more appreciated than the semi-didactic, large group
session that was used to introduce the model to the students. Rather than provide
stimulation and guidance for the subsequent scenario session, the overall effect of this
session was off-putting. In addition, there was little evidence to support a positive impact of
the model, the students appearing to be neutral to its benefit. A copy of the full report is
available on request from the authors.

In light of this evaluation by the students, the Faculty has reconsidered its use of the
consultation model. As a result, the model is now introduced in first year when students are
first asked to think about consultations and develop their own structure before being shown
the GVCCCM. Using this approach, the students take on more ownership of the model,
which is then used to evaluate videoed consultations in second year and as the basis of
feedback for role played sessions in third and fourth year.
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Evaluation of the use of the GVCCCM in undergraduate education – the


facilitator’s perspective.

Although the impact of the model directly on students was considered neutral, the model
has allowed positive changes to be made in curriculum design and facilitation.

In curriculum design, the model has provided a clear focus for scenario design and the
development of assessment. Role play scenarios are now developed with specific learning
objectives in mind and these can be based on the model. In addition, it provides a
‘curriculum’ around which assessment can be based. As a result, portfolio assessment of
communication skills has recently been introduced as a component of the final professional
exam at Liverpool. Students are required to use the model to assess both their own
consultations and those they see during clinical rotations. In this way, students are
assessed on their ability to evaluate communication, not on their ability to actually
communicate. In later years, it is planned to introduce communication role plays into an
objective, structured clinical exam in final year, during which student performance will be
assessed against the model.

After role-plays, informal feedback from facilitators has suggested that familiarity with the
model greatly facilitated feedback during group sessions. It allows facilitators to prioritise
feedback to students and contextualise it within the structure of the whole consultation. It
also allows group sessions to be structured, initially focussing on the early parts of the
consultation (e.g. preparation and opening the consultation) during their first role plays,
before moving on to more complex issues associated with gathering and giving information.
These benefits move communication skills training away from our early programme where
each student’s learning experience was very variable, towards a more structured and
defined experience. This has provided the basis to improve the students’ learning
experience. However, is has also bought the need for much greater facilitator training. In
order to make maximum use of the model during role plays, facilitators need to be very
comfortable with its use, initially to evaluate their own consultation and later in the
evaluation of others. This has generated a need for much more highly trained facilitators
than before the model was available, and is something that is being tackled at a national
level in the UK (see article by Carol Gray in same issue of JVME).
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Summary
Communication skills training is becoming recognised as an important part of the veterinary
curriculum. Before we had the model, facilitating was an easy task but the aims and
learning outcomes were ill defined and limited. The model opens up new and exciting
opportunities for teaching, learning and assessment of communication skills but will require
a cohort of facilitators skilled in the theory and use of the model. This necessarily places a
much greater emphasis on training of facilitators.

Developing the GVCCCM was an extremely rewarding academic exercise. Not only did it
generate a framework for future education, but its collaborative nature brought people
together to focus on communication training. This collaborative effort has been an
extremely valuable resource in the further development of communications skills training in
the UK, and is continued at regular national meetings. To the authors’ knowledge, the
GVCCCM is now being used at most of the veterinary schools in the UK and Ireland for
undergraduate education.

Acknowledgements
This project was funded by an educational grant from the Learning and Teaching Support
Network and further supported by Hills Pet Nutrition. The authors also wish to thank Dr
Rachel Howells from Cambridge Medical School for helpful discussions about the
adaptation of the Calgary-Cambridge model to the paediatric consultation.
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Figure legends

Figure 1. A summary flow diagram of the guide to the veterinary consultation based on the
Calgary - Cambridge model.

Boxes 2-9. Skills used in each section of the veterinary consultation based on the Calgary -
Cambridge model. Each point is numbered according to the original Calgary-Cambridge
model (1). Points beginning in zero or ending in a letter represent additions to the original
model.
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Figure 1
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Boxes 1 - 9

Box1; PREPARATION
Establishing context
0.a Familiarises with past history relating to client and animal(s).
0.b Anticipates potential conflicts or difficulties, relating to the client, the animal and to
systems infrastructures.

Creating a professional, safe and effective environment


0.c Ensures facilities / environment are professional and appropriate to anticipated
needs.

Box 2; OBSERVATION
0.d Continuous observation of the animal, the client and the environment.
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Box 3; INITIATING THE CONSULTATION


Establishing initial rapport with client and animal
1. Greets the client (and animal if appropriate); obtains / confirms the client’s name
and the name or identity of the animal(s).
2. Introduces self, role and nature of the consultation; obtains consent.
3. Demonstrates interest, concern and respect for the client and the animal.
3a. Attends to client’s and animal’s physical comfort.

Identifying the reason(s) for the consultation


4. Identifies the client’s problems or the issues that the client wishes to address with
appropriate opening question. e.g. “What’s the problem with Ginger today?” or
“What can we do for you today?”.
5. Listens attentively to the client’s opening statement, without interrupting or directing
the client’s response.
6. Checks and screens for further problems. e.g. “So you’ve noticed a drop in milk
yield.... is there anything else?”
7. Negotiates agenda taking both the client’s and veterinary surgeon’s needs into
account. e.g. “So we’ll look at the infected hoof first and then we’ll talk about the
milk yield.... is that okay?”
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Box 4; GATHERING INFORMATION

Exploration of client’s problems (includes long and short term


history).
8. Encourages client to tell the story of the animal’s problem(s) from when first
started to the present in their own words (clarifying reason for presenting now).
9. Uses open and closed questions, appropriately moving from open (“How’s her
appetite?”) to closed (“How often is she being sick?”).
10. Listens attentively, allowing the client to complete statements without interruption
and leaving time for the client to think before answering or go on after pausing.
11. Facilitates the client's responses verbally and non–verbally. e.g. use of
encouragement, silence, paralinguistics, body language, eye contact, repetition,
paraphrasing, interpretation.
12. Picks up verbal and non–verbal cues from the client (body language, speech, facial
expression); checks out and acknowledges as appropriate.
13. Clarifies statements that are vague or need amplification. e.g. “Could you explain
what you mean by drinking a lot”.
14. Periodically summarises to verify own understanding of what the client has said;
invites the client to correct interpretation or provide further information.
15. Uses concise, easily understood language, avoiding or adequately explaining
jargon.

Additional skills for understanding the client’s perspective


16. Determines and acknowledges:
• client’s ideas (i.e. beliefs regarding cause) and concerns (i.e. worries) regarding
each problem.
• client’s expectations: goals, what help the client had expected for each problem.
• effects: how each problem affects the client’s life.
17. Encourages expression of the client’s feelings and thoughts.
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Box 5;
Box 5; PROVIDING
BUILDING THE RELATIONSHIP
STRUCTURE WITH
TO THE THE CLIENT
CONSULTATION
Non-verbal behaviour
Making
22. organisation
Demonstrates overtnon–verbal behaviour e.g. eye contact, posture and
appropriate
position, movement, facial expression, use of tone.
18. Summarises at the end of a specific line of inquiry to confirm understanding before
23. If reads,onwrites
moving to thenotes or uses computer, does in a manner that does not interfere
next section.
with dialogue or rapport.
19. Progresses from one section to another using signposting; includes rationale for
next section. e.g. “I just need to ask you a few questions about Murphy before I
examine him”.
Developing rapport
Attending to flowclients views and feelings; accepts legitimacy; is not judgmental.
24. Acknowledges
20. Demonstrates
24a Structures consultation
understanding
in a logical
of animal’s
sequence.importance and purpose. e.g. shows
21. Attends to timing and keeping consultation on task. in which farming clients work,
understanding of the current economic environment
or the unique relationship that can exist between a companion animal and its
owner.
25. Uses empathy to communicate understanding and appreciation of the client’s and
animal’s feelings or predicament.
26. Provides support to the client: expresses concern, understanding, willingness to
help; acknowledges coping efforts and appropriate animal care; offers partnership.
27. Deals sensitively with embarrassing and disturbing topics and physical pain,
including when associated with physical examination of the animal.

Involving the client


28. Shares thinking with client to encourage client’s involvement. e.g. “What I’m
thinking now is.......”.
29. Explains rationale for questions or parts of physical examination that could appear
to be irrelevant.

Involving the animal (s)


30a. Acknowledges the animal and / or alerts animal to their presence.
30b. Relates to the animal taking into account the relationship between the client and
the animal. Approaches and handles the animal sympathetically.
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Box 6; EXPLANATION AND PLANNING


Providing the correct amount and type of information
Aims: to give comprehensive and appropriate information
to assess each individual client’s information needs
to neither restrict or overload
32. Assesses client’s starting point: asks for client’s prior knowledge early on when giving information, discovers
extent of client’s wish for information.
31. Chunks and checks: gives, in easily assimilated chunks, essential information regarding diagnosis and
treatment options, prognosis and financial implications; uses client’s response as a guide to how to proceed.
33. Gives other information according to the client’s wishes. e.g. aetiology.
34. Gives explanation at appropriate times: avoids giving advice, information or reassurance prematurely.
34a. Prioritises information given: recognises that some information may be best provided at a later time.

Aiding accurate recall and understanding


Aims: to make information easier for the client to remember and understand
35. Organises explanation: divides into discrete sections, develops a logical sequence.
36. Uses explicit categorisation or signposting. e.g. “There are three important things that I would like to discuss.
First...” or “Now, shall we move on to..”.
37. Uses repetition and summarising to reinforce information.
38. Uses concise, easily understood language, avoids or explains jargon.
39. Uses visual methods of conveying information: diagrams, models, written information and instructions.

40. Checks client’s understanding of information given (or plans made).

Achieving a shared understanding: incorporating the client’s perspective


Aims: to provide explanations and plans that relate to the client’s perspective
to discover the client’s thoughts and feelings about information given
to encourage an interaction rather than one-way transmission
41. Relates explanations to client’s initial concerns. e.g. previously elicited ideas, concerns and expectations.
42. Provides opportunities and encourages the client to contribute, to ask questions, seek clarification or express
doubts. Responds appropriately.
43. Recognises verbal and non-verbal cues e.g. client’s need to contribute information or ask questions,
information overload, distress.
44. Elicits client's beliefs, reactions and feelings regarding information given, terms used, financial implications;
acknowledges (empathises) and addresses where necessary. e.g. “I can see that this is upsetting for you.”

Planning: appropriate shared decision making


Aims: to allow clients to understand the decision making process
to involve clients in decision making to the level they wish
to increase clients’ commitment to plans made
45. Shares own thoughts: ideas, thought processes and dilemmas.
46. Offers choices rather than giving directives.
47. Encourages client to contribute their thoughts, ideas, suggestions and preferences.
48. Negotiates a mutually acceptable plan.
49. Encourages client to make decisions to the level that they wish – informed consent.
50. Checks with client if they accept plans, if concerns have been addressed.
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Box 7; CLOSING THE CONSULTATION


Summarising
51. Summarises session briefly and clarifies plan of care.

Forward planning
53. Safety nets, explaining possible unexpected outcomes, what to do if plan is not
working, when and how to seek help.
52. Contracts with client regarding the next steps for client, animal(s) and veterinary
surgeon.
54. Final check that client agrees and is comfortable with plan and asks if any
corrections, questions or other items to discuss.
54a. Says goodbye.
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References

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IR. (2003). The use of simulated clients in communication skills training for veterinary
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2. Kurtz SM, Silverman JD. The Calgary-Cambridge Referenced Observation Guides: an


aid to defining the curriculum and organizing the teaching in communication training
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3. Makoul G. Essential elements of communication in medical encounters: the Kalamazoo


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4. Kurtz S, Silverman J, Benson J and Draper J (2003) Marrying Content and Process in
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5. Kurtz, S., Silverman, J. and Draper, J. (2005) Teaching and learning communication
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6. Silverman, J., Kurtz, S. and Draper, J. (2005) Skills for communicating with patients - 2nd
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