Technology is increasingly proposed as a more efficient conduit to facilitate communication between generalist and specialist providers. However, little is understood about how to use these technologies to improve provider-to-provider collaboration and communication regarding specialist consultations. Electronic portals (e.g., EPIC, CPRS) serve an important role in enhancing connectivity between providers across service lines, but greater connectivity does not necessarily translate into greater collaboration.
One fundamental problem when consulting a specialist is that while generalists may have broad knowledge of patient psychosocial context, they may not know how to concisely formulate a specialty care consultation question to communicate the range of medical, psychological, and social issues when dealing with complex chronic illnesses. Our team has video-recorded over 127 hours of generalist-specialist consultations using a video telemedicine interface. Using specialized software, we developed an algorithm to analyze the consultation into time-encoded components of the consultation process, such as patient case presentation, presentation of the primary consult question, case discussion and negotiated care decision making, and social talk between providers.
Our findings indicate that when making a specialty referral, generalists are faced with two problems. First, some generalists are unaware of the required prerequisites, such as documentation of diagnostic results such as labs, imaging, etc. to document a possible specialty care problem prior to referral. Relatedly, because of their broad training, generalists may not be able to pose specific and concise questions. As a result, consultation requests can be administratively delayed or rejected or misunderstood, which can compromise patient safety, timely response to patient concerns, and effective care coordination Second, generalist providers can sometimes be intimidated by specialty providers, which can contribute to strained interpersonal and working relationships.
To remedy these problems, we propose an interactive training intervention using the Conversation Analytic Role-play Method (CARM), a communication skills training and assessment method. CARM interventions expand participants’ knowledge of effective and ineffective communication and enable participants to practice communication techniques to solve problems they may encounter in actual situations. CARM uses a novel simulation technique as the primary educational strategy in which audio or, preferably, video recordings are shown and reviewed to slow down real-time events with the goals of examining the communication process in forensic detail, discussing possible responses, and practicing new communication skills in a group format.
We will use CARM to develop an intervention with our previously video recorded consultations and the resulting analysis. The overall goals of the intervention will be, first, to educate providers about effective and ineffective communication strategies when referring a patient to specialty care, and second, to give generalist and specialist providers an opportunity for social interaction during a shared didactic experience. These combined goals will address the problems identified in our research to date. We anticipate developing between three and five training modules of different durations from 15 to 30 minutes in length that can be disseminated in person and/or via video teleconference to facilitate busy provider participation. Training sessions will combine didactic and interactive components. The didactic component will use anonymized segments of video data to illustrate key principles of effective and ineffective clinical communication. Interactive components will ask participants to role-play as both a group and as individuals to practice the communication skills introduced and discussed during the didactic component. Participants will be a combination of generalist and specialist providers.
We will evaluate our intervention using a mixed methods approach. Quantitatively, we imagine using a basic pre-post design in which provider participants’ knowledge, attitudes, and beliefs are measured using surveys. Qualitatively, we imagine conducting brief semi-structured interviews with generalist-specialist participants. Together, the quantitative and qualitative data will be used to gauge acceptability of the intervention and to assess changes in 1) specificity, concision, and clarity in consult communication; and 2) interpersonal relationship between generalist and specialist providers. The evaluation will be guided by the Knowledge to Action framework (Graham, Logan, Harrison, et al. 2006), a theory-based conceptual model used to help translate knowledge for continuing health professionals' education. This framework has been successfully used both to understand and to influence sustainable change in a range of clinical practice settings.
This proposed project leverages our previously collected data in order to improve communication effectiveness between generalist and specialist providers when requesting consultation. The intervention provides participants with specific communication tools to address a high-stakes work-related task for which both generalist and specialist providers have a substantial professional interest. Simultaneously, the intervention supplies generalist and specialist providers an opportunity for a shared experience, which has the potential to facilitate increased interpersonal connection. We believe this proposal has the potential to improve the coordination of care between providers, timely access to specialty care services, and, ultimately, the overall quality of patient care.
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