Modification of Calgary-Cambridge Observation Guide , a more simplified and practical communication guide for daily consultation practice

Background: The Calgary-Cambridge Observation Guides (CCOG) is a guide that is widely used to assess Doctor-Patient Communication. The guide consists of 56 points divided into 6 categories that describe a routine consultation process, plus 15 optional points in giving explanation and planning. Due to its quite numerous points, it is quite impractical to use the guide in daily consultation practice. Therefore, a more simplified and more practical version would be favourable. Method: Seven experts from different background evaluated and analysed the 56 points of CCOG based on the level of importance in daily practice. Two rounds of Delphy were used in the study, the first round to evaluate level of importance, and the second to obtain the possibilities to join items that may have similar meaning. The result of the two rounds was then recirculated to all members of the team for confirmation of the final modified version of CCOG. Results: A final modified version of CCOG consisting of 35 points was formed. The first step of a consultation process, Initiating the session consists of 5 points (originally 7 points). Gathering information step consists of 5 points (originally 11 points), Providing structure of 3 points (originally 4 points), Building relationship of 7 points (originally 10 points), Explanation and Planning of 11 points (originally 20 points), and Closing the Session consisting of 4 points. The modified CCOG version is still comprehensive, yet more practical for daily practice. Conclusion: Modified version of CCOG can be used as a simple, practical guide to assess Doctor Patient Communication in daily consultation practice. (Health Science Journal of Indonesia 2017;8(2):111-7)

Good doctor-patient communication offers patients tangible benefits.Many studies have found positive associations between doctors' communication skills and several factors: increased understanding & recall, symptom relief, adherence & concordance, improved health outcomes and physiological outcomes, patient safety, patient satisfaction and doctor satisfaction.[3] However, doctor patient communication is difficult to learn because of its delicate process, therefore it needs a clear and systematic guide and assessment tool. 1 There are several examples of communication assessment tools: Kalamazoo Checklist, 4 SEGUE Framework, 5 MAAS Global Communication tool, 6 etc.One of the guides that is widely used in many countries is The Calgary Cambridge Observation Guide. 1,2The guide was developed by a team from The University of Calgary in Canada and The University of Cambridge in England.It describes one approach for delineating and organizing the specific skills that research supports for communicating effectively with patients.The guide consists of 56 points divided into 6 categories that describe a routine consultation process: Initiating the Session, Gathering Information, Providing Structure, Building The Relationship, Explanation and Planning, and Closing the Session, plus 15 options points in giving explanation and planning. 1,2e guide provides a comprehensive approach to assess doctor patient communication in a consultation process.It delineates and briefly defines the 71 core communication process skills.Yet, in daily consultation practice in many countries in which time constraint is present and the number of patients is very big, it is quite impractical to use CCOG.One of the main reasons is its quite numerous points.A comprehensive guide less number of points and easy to remember would be of benefit.Therefore, a more simplified and more practical version would be favourable.The objective of this study is to obtain a modified version of CCOG that is more simplified and more practical.

METHODS
The study is a type of study known as instrument development.This type of study usually consists of several processes, including developing, testing, and using the instrument.In this study we conducted modification of existing guide in doctor-patient communication.
We invited 7 experts from different background (1 professor expert of doctor-patient communication field, 2 professors of internal medicine, 1 professor of pulmonology, 1 professor of psychiatry, 1 PhD in Occupational Medicine).They are clinical experts in their field of work as well as senior lecturers from the Faculty of Medicine Universitas Indonesia/Cipto Mangunkusumo National Central General Hospital in Jakarta, Indonesia.They are also members of Doctor-Patient Communication Trainer team in the Faculty of Medicine Universitas Indonesia.Past President of Indonesian Medical Association was invited to join the team because once the modification is completed, it can be used for medical doctors, members of the Indonesian Medical Association, who practice in health facilities across the nation.The team was asked to evaluate and analyse the 56 points of CCOG based on the level of importance in daily practice.
During the process, cultural competence according to Indonesian condition was used.This includes consideration on the number of patients a doctor would see in a session, time limitation for each session, and types of patients (new patients vs. follow up patients).
Two rounds of Delphy method were used in the study, in the first round expert gave scores based on Likert scale of 1 to 5 (1 being least important, 5 being most important) to the 56 points of CCOG.The result of this step is a shorter list that contains points regarded as important by the experts.Experts also stated that some points need to be combined because they refer to similar steps/points.In the second round, experts were asked which of the CCOG points (result of round 1) combined and modified.This round resulted some points be combined and modified, thus making the points in CCOG even more compact and shorter.
The result of the two rounds was then recirculated to obtain confirmation of the final modified version of CCOG.

RESULTS
A final modified version of CCOG consisting of 35 points was formed.The first step of a consultation process, Initiating the session consists of 5 points (originally 7 points).Gathering information step consists of 5 points (originally 11 points), Providing structure of 3 points (originally 4 points), Building relationship of 7 points (originally 10 points), Explanation and Planning of 11 points (originally 20 points), and Closing the Session consisting of 4 points.The following diagram describes the changes.

DISCUSSION
There are other communication assessment tools besides the CCOG, that has been used in many countries. 8,9Medical Profession in the USA uses Essential Communication Skills in the Medical Encounter adapted from The Kalamazoo Consensus Statement.The consensus consists of 7 key elements of communication in clinical encounters: build the relationship, open the discussion, gather information, understand the patient's perspective, share information, reach agreement, and provide closure. 4.11 SEGUE Framework is a research-based checklist of medical communication tasks.As an instrument for the observation of provider-patient interviews. 5t has 32 items with yes/no options divided in six domains.Topics covered by this instrument are: Set the stage, Elicit information, Give information, Understand the patient's perspective, and End the encounter.SEGUE Framework is the most widely used structure for communication skills teaching and assessment in North America.It has a high degree of acceptability, can be used reliably, has evidence of validity, and is applicable to a variety of contexts. 5 the Netherland MAAS-Global (Maastricht History-taking and Advice Scoring) that was developed in Maastricht University has been widely used to evaluate clinical communication skill. 12It is an instrument to rate communication and clinical skills of doctors in their consultations.This Instrument for the observation of provider-patient encounters includes three sections: section 1: communication skills for phases of the encounter; section 2: general communication skills that include communication skill that may take place in each consultation phase or during a consultation process; and section 3: medical aspect that is meant to assess the content of a consultation during history taking, physical examination, diagnosis, and treatment; There are 17 items of the instrument, Rating is done using a 7-point scale.The MAAS-Global-D instrument, which measures communicative and medical skills, has recently been translated into German and used in a research to assess communication skill of Primary Care Physician. 13 Identifies the patient's problems or the issues that the patient wishes to address with appropriate opening question (e.g."What problems brought you to the hospital?"or "What would you like to discuss today?" or "What questions did you hope to get answered today?"). 4 Listens attentively to the patient's opening statement, without interrupting or directing patient's response.5 Confirms list and screens for further problems (e.g."so that's headaches and tiredness; anything else……?").GATHERING INFORMATION  6  Encourages patient to tell the story of the problem(s) from when first started to the present in own words ( Certainly each instrument has its strength and weaknesses.Compared to the other instruments, CCOG can be used as a framework for communication process as well as an instrument for evaluation.An example of its use is during an OSCE to assess communication skill, and during a training in which participants receive feedback for their performance during a consultation process. 14The Kalamazoo consensus statement is a brief instrument consisting of 7 items, however its use as an instrument to assess communication skill is more difficult, since most of its points are quite general for a consultation process.One difficulty of using the SEGUE framework in real situations is the duration of the interviews.Within the 25-minute interviews, the parameters of the SEGUE framework applied to encounters with Standardized Patients in controlled situations more easily than to encounters with Real Patients. 15MAAS Global is actually quite brief, because it consists of 17 items.However, a closer look at the instrument will reveal that each item may contain 3-4 indicators, which eventually lead to quite numerous guide too.This is why CCOG if more preferable to use, because it can describe a consultation process comprehensively from the beginning to the end of a consultation process.
In conclusion, CCOG can be used as a simple, practical guide to assess Doctor Patient Communication in daily consultation practice.The guide has been modified and made simple, containing 35 points.It is expected that the modified guide will be used widely as an instrument to guide and assess doctor patient communication in daily consultation practice.

Table 1 .
The Original Calgary-Cambridge Observation Guide Greets patient and obtains patient's name 2. Introduces self, role and nature of interview; obtains consent if necessary 3. Demonstrates respect and interest, attends to patient's physical comfort Identifying

the reason(s) for the consultation 4. Identifies the
patient's problems or the issues that the patient wishes to address with appropriate opening question (e.g."What problems brought you to the hospital?"or "What would you like to discuss today?" or "What questions did you hope to get answered today?") 5. Listens attentively to the patient's opening statement, without interrupting or directing patient's response 6.Confirms list and screens for further problems (e.g."so that's headaches and tiredness; anything else……?") 7. Negotiates agenda taking both patient's and physician's needs into account GATHERING

INFORMATION Exploration of patient's problems 8. Encourages patient to tell the story
of the problem(s) from when first started to the present in own words (clarifying reason for presenting now) 9.

Uses open and closed questioning technique, appropriately
moving from open to closed 10.Listens attentively, allowing patient to complete statements without interruption and leaving space for patient to think before answering or go on after pausing 11.Facilitates patient's responses verbally and non-verbally e.g.use of encouragement, silence, repetition, paraphrasing, interpretation 12. Picks up verbal and non-verbal cues (body language, speech, facial expression, affect); checks out and acknowledges as appropriate 13.Clarifies patient's statements that are unclear or need amplification (e.g."Could you explain what you mean by light headed") 14.Periodically summarises to verify own understanding of what the patient has said; invites patient to correct interpretation or provide further information.15.Uses concise, easily understood questions and comments, avoids or adequately explains jargon 16.

Establishes dates and sequence of events Additional skills for understanding the patient's perspective 17. Actively determines and appropriately explores:
• patient's ideas (i.e.beliefs re cause) • patient's concerns (i.e.worries) regarding each problem • patient's expectations (i.e., goals, what help the patient had expected for each problem) • effects: how each problem affects the patient's life 18.Encourages

patient to express feelings PROVIDING STRUCTURE Making organisation overt 19. Summarises at
the end of a specific line of inquiry to confirm understanding before oving on to the next section 20.Progresses from one section to another using

signposting, transitional statements; includes rationale for next section Attending to flow 21. Structures interview in logical sequence 22. Attends to timing and keeping interview on task BUILDING RELATIONSHIP Using appropriate non-verbal behaviour 23. Demonstrates appropriate non-verbal behaviour
Deals sensitively with embarrassing and disturbing topics and physical pain, including when associated with physical examination Involving the patient 30.Shares thinking with patient to encourage patient's involvement (e.g."What I'm thinking now is....") 31.Explains rationale for questions or parts of physical examination that could appear to be non-sequiturs 32.During physical examination, explains process, asks permission

EXPLANATION AND PLANNING Providing the correct amount and type of information
Organises explanation: divides into discrete sections, develops a logical sequence 38.Uses explicit categorisation or signposting (e.g."There are three important things that I would like to discuss.1st..." "Now, shall we move on to.") 39.Uses repetition and summarising to reinforce information 40.Uses concise, easily understood language, avoids or explains jargon 41.

Uses visual methods of conveying information: diagrams
, models, written information and instructions 42.Checks patient's understanding of information given (or plans made): e.g. by asking patient to restate in own words; clarifies as necessary Achieving

a shared understanding: incorporating the patient's perspective Aims
: • to provide explanations and plans that relate to the patient's perspective • to discover the patient's thoughts and feelings about information given • to encourage an interaction rather than one-way transmission 43.Relates

explanations to patient's illness framework: to
previously elicited ideas, concerns and expectations 44.

Provides opportunities and encourages patient to contribute: to
ask questions, seek clarification or express doubts; responds appropriately 45.

Picks up verbal and non-verbal cues
e.g.patient's need to contribute information or ask questions, information overload, distress 46.

Elicits patient's beliefs, reactions and feelings re
information given, terms used; acknowledges and addresses where necessary

Shares own thinking as appropriate: ideas, thought processes, dilemmas 48. Involves patient:
Contracts with patient re next steps for patient and physician 54.Safety nets, explaining possible unexpected outcomes, what to do if plan is not working, when and how to seek help Ensuring appropriate point of closure 55.Summarises session briefly and clarifies plan of care 56.Final check that patient agrees and is comfortable with plan and asks if any corrections, questions or other items to discuss

Table 2 .
The Modified Version of The Calgary-Cambridge Observation Guide Listens attentively, allowing patient to complete statements without interruption and leaving space for patient to think before answering or go on after pausing.9 Facilitates patient's responses verbally and non-verbally e.g.use of encouragement, silence, repetition, paraphrasing, interpretation, Picks up verbal and non-verbal cues (body language, speech, facial expression, affect); checks out and acknowledges as appropriate.10 Clarifies patient's statements that are unclear or need amplification (e.g."Could you explain what you mean by light headed").
33 Safety nets, explaining possible unexpected outcomes, what to do if plan is not working, when and how to seek help.34Summarisessessionbrieflyand clarifies plan of care.35Finalcheck that patient agrees and is comfortable with plan and asks if any corrections, questions or other items to discuss.