Impact case study database

Through a multi-pronged programme of impact activities, the research has:

1. Been used to train medical students and practitioners in communication skills.

2. Directly influenced medical curricula and medical educators.

3. Been included in two sets of national clinical communication guidelines (Netherlands and UK).

These impact activities are highly significant because, as noted above, involving patients in decision-making is a widespread ‘best practice’ requirement, but there is extensive evidence that clinicians find it difficult to do. The impact activities have achieved notable reach, having made a positive difference in four countries across two continents (Brazil, the Netherlands, Norway, the UK), reaching four types of beneficiary: medical students, medical practitioners, healthcare educators and medical guideline producers. The research findings have been used across multiple specialties, including neurology, general practice, ophthalmology, and emergency medicine.

Impact 1. A documented, positive change in medical students’ and practitioners’ awareness, understanding and practice regarding how best to offer patients choice.

This was achieved by delivering evidence-based communication skills training, in person, to over 200 medical students and practitioners, including end-of-project NIHR-funded workshops for neurologists in the UK (Glasgow and Sheffield), and invited workshops for psychiatrists in Glasgow, medical students and practitioners in Brazil, and ophthalmic practitioners and trainees in Belfast. These have been described as a “ *perspective-changing learning experience… not just for the future profession but for their next-day practice already!*” (Medical Educator, Brazil) [1a]. Student participants reported rapidly utilising what they had learnt, despite this often being at odds with what they observed their supervisors doing [1b][1c][1d]. One drew upon the training to counter a professor’s suggestion that they tell a patient what to do: “ In that moment all my studies of patient choice made complete sense and I said, ‘why don’t we ask the patient what she would like?’” The professor agreed, and the patient’s positive response has convinced the student to implement patient choice in her future practice [1d]. Experienced medical practitioners reported “ more awareness of my own practice” (Optometrist, Belfast) [1e] and positive changes following the training: “ I used to think that my practice included patient’s choice. But now I am beginning to realize that there are many more situations, such as decisions about medical procedures, exams, besides treatment!... It has already started! Today in my practice I have realized my opportunities to introduce choices in medical decisions!” (Neurologist, Brazil) [1e].

A two-hour e-learning package, called ‘Patient Choice in Practice’, was developed to augment the face-to-face workshops that were curtailed by the COVID-19 pandemic, as well as to ensure longevity and reach of the training (see also Impact 2, below). This was piloted in 2020 with 55 medical students in Brazil, who also received a three-hour online workshop (delivered twice by Toerien), with real-time translation into Brazilian Portuguese. Positive evaluations by participants were publicly reported on the Unisinos news pages: “ I was able to deepen and solidify my knowledge… how to bring these options… giving space for the patient to bring their thoughts, values ​​and desires in relation to that decision… the knowledge acquired in the workshop makes my practice even more respectful, sensitive to the other” [2]. Formal evaluation was conducted using pre- and post-training questionnaires. These showed that the training led to a statistically significant increase (Wilcoxon Sign rank test) in participants’ confidence in how to offer patients choice [3], particularly through the skills taught around option-listing and seeking patient views: “ The most important thing I learned was how to include the patient in the decision (through the use of ALF and, mainly, PVEs). After the workshop, I concluded that, during our practices, we disseminated many more recommendations than shared decision-making processes, without even realizing it. So, I leave this workshop much more aware of this” [3]. The majority of participants (80%) reported that they would now offer choice in situations when they would not have done so before the training [3].

Impact 2: A lasting change in medical curricula and medical educators’ approach to communication skills training. The repeat invitation to Toerien (2019 and 2020) to provide training on patient choice to the medical students at Unisinos (Brazil) represents a lasting change to the curriculum. This will continue directly through the Patient Choice in Practice e-learning package, which has been adopted for ongoing use at Unisinos [1a][4], Queen’s University Belfast [5] and Manchester Medical Schools. As a medical educator at Manchester Medical School notes: “The Patient choice in Practice eLearning package addresses a crucial part of communication in clinical care. Rather than training based on simulated clinical practice, it uses real clinical encounters to encourage participants to think critically about how to balance patients’ right to choose with the practitioner’s duty of care. This will provide clinicians with greater authenticity in the teaching presented to them and greater clinician acceptance of the learning it provides. The package dovetails with other areas of communication training and addresses a curriculum gap” [6]. The medical educators also report how the research has influenced their own teaching: “ the workshop Patient Choice in Practice generated impact on my teaching to second year-med students… I, along with the lead tutor of Language and Interaction in Healthcare, have referred to [Toerien et al’s] work in class… and we agreed to permanently incorporate [their] work on the syllabus we will be offering” [4].

Educators in Norway have incorporated the research in continuing professional development training: “Findings from [Toerien et al’s] research have been amongst the key take home messages in lectures I’ve delivered on how to achieve patient choice and shared decision making in practice. This is one of the most challenging communicative tasks in modern health care, and [Toerien et al’s] empirical findings are powerful in demonstrating how it can be accomplished in practice” (educator responsible for training over 200 Norwegian specialists in general medicine and ophthalmology, at Stavanger University Hospital) [7]. For those who teach and practice medicine, the research has had a double impact. “[Toerien et al’s] papers on patient choice have greatly influenced my thinking and knowledge around (shared) decision making, both with regards to my own research, clinical practice and my teaching these subjects at UiT the Arctic University of Norway’s medical school… students have been very engaged with the issues [Toerien et al have] raised, prompting important learning about and hands-on training in communicating with ‘difficult’ patients… and patients with chronic disease” (Head of the Emergency Department of Nordland Hospital) [8]. The research impact in Norway will have longevity because the “findings about what constitutes patient choice have also been given a prominent place in the first conversation analytic introductory book in Norwegian, focusing on conversation as a tool for professional practice” [7]. This includes a translation of material from the final report [A].

Impact 3: Inclusion of the research findings in two national clinical communication guidelines (in The Netherlands and the UK). As a result of delivering the keynote based on her research – described as an “eye-opener” [9a] – at the 2019 Dutch GP Science Day, Toerien was invited to provide “expert input” [9a] into the first clinical communication guidelines, developed by the Dutch College of General Practitioners (Nederlands Huisartsen Genootschap; NHG). Toerien delivered findings from the research on patient choice as well as an overview of CA findings on GP consultations in a 45-page report [9b] and 6 hours of discussion of the evidence with the NHG Programme Manager for Person-Centred Care. She reports: “I am extremely pleased with the way [Toerien] was able to apply [her] scientific knowledge on CA to day-to-day GP practice. I learned a lot about patient choice in practice, which is a very important step for shared decision-making… [Toerien’s report] provides a sound basis and it will be easy to translate the evidence into the communication modules” [9a]. The final production of the guidelines has been delayed due to COVID-19, but it has been confirmed that Toerien’s input will definitely be included [9a]. The guidelines will be applied in e-learning programmes developed by the NHG in order to make current knowledge on communication easily accessible to all Dutch GPs. “The goal is to improve the clarity of GPs’ communication – making it easier for patients to understand their diagnosis and any treatment options – and to equip GPs to know how to solicit patients’ own concerns and preferences as the basis for a patient-centred approach to healthcare” [9a]. In contributing so extensively to the development of these guidelines, then, the research will benefit not only all Dutch GPs but the patients with whom they communicate on a daily basis.

The e-learning materials have also been accepted for inclusion in a comprehensive set of training resources to support clinicians across the UK to enact the NICE Shared Decision-Making (SDM) Guidelines [10]. NICE will publish these guidelines in June 2021 but recognise that guidelines alone are not sufficient to counter the difficulties clinicians experience in enacting SDM. Acknowledging that “much centres on consultation skills” and that the current approach to training is inadequate, the NICE team see significant benefits to the novel approach taken in the e-learning package: “we were delighted to be made aware of the York research and resources. They have the capacity to re-energise the rather ‘stuck’ consultation skills teaching and learning silo, and link that with shared decision making, which is under-done in practice. We were also delighted to see ‘Three things to remember’ as opposed to 78 items in the Calgary Cambridge consultation model. The tone of the materials is just excellent, especially the approach of adaptation by learners of their natural style rather than an external imposition of some standardised approach” [10]. Agreement has been reached to include “highlighted edits from the existing [e-learning] content in the Keele/NICE SDM resources” as well as a link enabling learners to access the full package [10]. The use of these materials by NICE will ensure that clinicians across the UK are supported to enact patient choice in the most effective way. As with the Dutch GP guidelines, this will not only benefit clinicians by enhancing their professional conduct but will help to realise the NHS’s goal for patients to be active partners in decision-making, summarised in the well-publicised phrase: “no decision about me, without me” (Department of Health, 2012).

Toerien and Jackson’s pioneering research-based training in specific, practical communication skills has had a demonstrable, positive impact on medical students’ and practitioners’ ability and willingness to give patients choice. The longevity and reach of the impact has been secured through the e-learning package and by the uptake of the research findings by high-profile medical professionals and governing bodies including those with direct responsibility for medical training and guideline development. This ensures that the research will continue to help practitioners – internationally and across medical specialties – transform shared decision-making from an ideal to a reality in their daily interactions with patients.