Communication between Older PTs and Their MDs

Ronald D. Adelman, MD

Michele G. Greene, DrPH

Risa Breckman, LCSW

Communication between Older PTs and Their MDs

• Why is older PT-MD communication important?

• What makes communication in the geriatric medical encounter different?

• The role of the third (or more) person in the medical encounter

• Practical communication skills for the geriatrician

• Accessing the psychosocial history

Why is Older PT-MD Communication Important?

PT OUTCOMES:

• Satisfaction• Adherence to medication regimens and

other therapeutic recommendations• Knowledge and recall• Utilization of health services and

associated costs• Health status

MD Outcomes

• Satisfaction

• Malpractice suits

• Ability to diagnose and treat

• A more difficult-to-capture and intangible outcome of MD-PT communication is the development of a healing relationship based on trust, empathy and masterful medical care.

What makes communication in the geriatric medical encounter

different?

• Attitudes toward older people

• Medical issues

• Psychological and social issues

Attitudes Toward Older People

• Ageism is the system of destructive false beliefs about older people

• We live in an ageist society – what are the implications?

Ageism

• Ageism is found among health care professionals

• Stereotyping can lead to misattributions and inadequate medical intervention

• Ageism is the last acceptable “ism”

• Ageism is found among older people themselves

What makes medical issues in the geriatric visit different?

• Multiple chronic illnesses

• Atypical presentation of disease

• Polypharmacy

• Multiple MDs

• Importance of team

What makes medical issues in the geriatric visit different?

• Sensory issues

- decreased hearing

- decreased vision

• Cognitive issues – more common in the old-old

- dementia-ism – stereotyping of all PTs with dementia as the same

What makes psychosocial issues in the geriatric visit different?

• Psychological and social issues- e.g., more losses (bereavement,

function) - fears about their own future, dependency - caregiving issues - social isolation

• Goals of care, advance directives, meaning, end-of-life care

What makes communication in the geriatric medical encounter

different?

• Presence of third (or more) person in the medical visit

Setting the Stage

- PT = 91 years old

- Accompanied to the visit by her daughter-in-law

- MD is an internist with no geriatric training

- PT and MD have known each other for 5 years

Dyadic vs Triadic Visits• Older PTs were frequently excluded from

conversations in which the third person was present

• Older PTs were less assertive, expressive, and had less joint decision-making and shared laughter in triads than in dyads

• Older PTs raised fewer topics in triads than in dyads

• Older PTs were less responsive to their own topics in triads than in dyads

Effective Communication Skills in Geriatric Medicine

• MDs and PTs are in agreement that there is inadequate time available for the visit.

• Many geriatricians realize that the initial intake may take 2 or 3 visits.

• Time spent learning the identity of the PT early in the relationship will save time later on.

Developing the Relationship

• Most PTs evaluate MDs based on their interpersonal skills and not on their medical knowledge and technical skills

• Introduce self

• Shake hands; sit down

• Obtain permission for third person to be present

Developing the Relationship

• Ask PT’s preference for form of address

• Utilize appropriate social amenities (e.g., “how nice to meet you,” “thank you”)

• Provide orientation to the visit

• Determine the patient’s agenda

• Pay attention to nonverbal cues

Effective Communication Skills

Identify sensory deficits that may impact communication:

Vision - sit close to the PT - make sure the room is well-lit - utilize large print educational materials and formsHearing - amplification devices - clear view of mouth for lip-reading

- speak up, do not mumble, enunciateFunctional deficits - help PT to examining table

- determine if PT needs help with undressing - impact of environment

History-Taking

• Use open-ended questions

• Listen to responses and allow the PT to speak for several minutes

• Avoid interruptions

• Establish an atmosphere in which sensitive issues can be raised (e.g. normalize difficult topics)

• Avoid litanies

Combating Ageism

• Obtain a life history to access personhood of the patient

• Health promotion/disease prevention

• Offer state-of-the-art medical care

• Avoid misattributions

• Eliminate patronizing talk

• If there is an accompanying person, talk to the patient

History-Taking of Psychosocial Content

• MDs may not want to raise psychosocial issues with older PTs as they do with younger PTs

• In a recent study, depression was discussed in only 7% of follow-up geriatric visits.

• Psychosocial screening tool

Providing Information

When PTs do not understand what is wrong with them, they are less able to take an active role in their care.

• Avoid technical language and jargon

• Determine PT’s level of health literacy

• Young-old consumerist perspective

• Provide most important information first

Providing Information

• Do not overload

• Have PTs repeat back what they have learned

• Provide take-home educational materials

Effective Communication Skills

• Power of touch

• Joint decision-making

• Shared laughter

• Physician “memory”

• Use of phone

Effective Communication Skills

Assessing cognitive impairment

- PTs want MDs to initiate discussion of cognitive issues

- Normalize discussion of cognition

- Importance of MD reassurance and support

- Importance of family member or significant other

Effective Communication Skills for PTs with Cognitive Impairment

1. Be memory trigger for PTs2. Give ample time for PT responses. Avoid interruptions.3. Focus on information exchange rather than PT’s accurate use of words.4. Speak clearly and slowly5. Be the soother rather than provocateur6. Use yes/no or close-ended questions