basic doctor skills em conference 5/15/08 joshua rocker, md pediatric emergency medicine schneider...
TRANSCRIPT
BASIC DOCTOR SKILLSEM Conference 5/15/08
Joshua Rocker, MD
Pediatric Emergency Medicine
Schneider Children’s Hospital
Much of this talk is extracted from articles I read and a lecture I heard from Robert Strauss, MD (EM attending in Poughkeepsie, NY)
What makes a good ER doc?
Are you a good ER doc?
?
How can I become a better ER doc?
?
How do we measure our abilities?
?
What the ACGME expects of you- Core Curriculum!
Patient Care Medical Knowledge Practice-based Learning and
Improvement Interpersonal and Communication Skills Professionalism Systems-Based Practice
Are your thoughts and the ACGME’s consistent?
Why not?
Because… Competitive med school/residency
atmosphere (skills, knowledge based) Teaching communication/ compassion/professionalism is not easy It requires the educator to be a good
communicator and that is not simple It requires confronting residents regarding
personal issues
Another measure of our performance
Press-Ganey Scores
5 Press-Ganey Scores (MD) Did the doctor spend enough time with
you? Did the doctor keep you informed in a
language you understand? Did the MD seem attentive to your
questions and worries? Was the MD friendly and caring? Did you trust your MD?
Press-Ganey Scores…
Did they ask about skills or knowledge?
What are your mother’s or grandmother’s comments about their doctors?
What we notoriously do
Interrupt patients early in the encounter Fail to identify and prioritize patient’s
concerns Miss opportunities to understand and
acknowledge patient’s ideas and feelings Fail to understand importance of culture
and ethnicity
More things we do wrong
Minimize patient’s role in their own care Underestimate pts health literacy Don’t negotiate differences well Don’t give bad news concisely and
compassionately
Communication Skills
When was the last time someone commented on your communication skills? Towards colleagues? Towards patients?
Communication Skills
Was that feedback helpful? Was it constructive? Did it change your behaviors?
OKAY, IS THIS HOUR GOING TO BORE ME?
OKAY, IS THIS HOUR GOING TO BORE ME?
Why waste my time with this med school bullshit!
Localio, NEJM, 7/91
For every 7.6 negligent adverse event there is only 1 lawsuit
Levinson, JAMA, 2/97
Comparing MDs with no lawsuits and MDs with lawsuits Those with no cases
• Educated pt re: expectations• Sense of Humor• Solicited pt opinion• Checked pt understanding• Encourage pt to talk• Spent more time on routine visits
Hickson, JAMA, 10/94
Comparing Ob/Gyns with little to no lawsuits vs those with many
Quality of care, same
Perception of care, different
Basic facts about proper communication skills
Greater patient and clinician satisfaction Greater patient understanding and
acceptance of treatment plan Reduce patient distress FEWER LAWSUITS
Marvel, JAMA, ‘99
25% of FM MDs in their offices did not solicit pts concern, ask why pt was there, or how they can help
28%- did all
Time difference between their interactions:
Marvel, JAMA, ‘99
25% of FM MDs in their offices did not solicit pts concern, ask why pt was there, or how they can help
28%- did all
Time difference between their interactions:
6 Seconds
I am what I am… “Meaning well and trying hard do not
guarantee a good outcome.”
“It takes 18 months to 2 years to change a behavior… and you’ve really got to want to.”
Harles Cone
I can’t change!
Interventions directed to improve clinician-patient communication demonstrated
Better patient self-management of DM Reduction of post-op morbidity Better coping and quality of life with cancer
SKILLS
1. Identify and remove barriers to communication
Physical Psych/Social Cultural
SKILLS
2. Survey patient’s concerns
Ask
Don’t just listen to the facts/details, sense their emotions
SKILLS
3. Care
Listen with eyes and body Remain silent Be empathic
SKILLS
4. Negotiate a consensual agenda
Work with patient Make sure they understand and agree with
plan, otherwise… non-compliance (whose fault is that!)
Josh, wake up… that will take forever
Josh, wake up… that will take forever
Evidence shows that these skills and the skills of making explicit empathic and caring statements in the end saves time
Albert Mehrebian on Persuasion (%)
Verbal content Vocal Expression Visual Cues
Albert Mehrebian on Persuasion (%)
Verbal content 7% Vocal Expression 38% Visual Cues 55%
Mehrebian on Persuasion
We tend to overemphasize the content, to convince them with words. If they are not getting it, perhaps… you’re not delivering it
Gorlin, NEJM, ‘83
MDs frequently react to difficult situations with avoidance Become hostile/angry Feel Loss of control
Gorlin, NEJM, ‘83
Recommendations-• Acknowledge your response• Accept response is justified, but ill advised
(Raul May- “What makes us humans is the time between impulse and action.”)
Clip of interaction….