Effective Communication Skills with Families and Colleagues

CMH Fellows CurriculumAugust 7, 2007

 Timothy P. Hickman, MD, MEd, MPH

Associate Professor, Department of Pediatrics and Department of Medical Education and Research

Cultural Competency MasterOffice of Cultural Enhancement and Diversity

University of Missouri-Kansas City School of Medicine

Learning Objectives

• Describe research in parent-provider-child communication in pediatrics

• Discuss communication styles and how they might effect interdisciplinary and patient communication

• Identify approaches to taking a history that will elicit health beliefs and traditional medical practices from any patient

• Discuss incorporating a cultural history into the clinical history

ACGME Core Competencies Addressed

• Patient Care

• Interpersonal and Communication Skills

• Professionalism

Communication Quotient Activity

Cincinnati Children's Study

• Methodology– Survey of Attending Physician, Nursing Staff,

and Parents– Probably Case Series Design (Baseline for

RCT)

• Sample– 44 PGY1 residents scheduled for pediatric

rotations (8 not eligible)– Physician, Nurses, Parents: Convenience

sampleBrinkman, 2006

Cincinnati Children's Study

0

20

40

60

80

100

Per

cen

t Y

es

ShowingInterest

Respectful Explained Listened SharedDecisions

Parent and Physician Rating of Residents

Physician

Parent

Brinkman, 2006

Significant Differences

• Physician > Parent Rating of Residents– None

• Parent > Physician Rating of Residents– Sharing Decisions (p<0.3)

Brinkman, 2006

Cincinnati Children's Study

0

20

40

60

80

100

Per

cen

t Y

es

RespectStaff

AcceptSuggest.

RespectConfident.

Comm. withStaff

Comm. WithPt/Fam

Nursing Staff and Physician Rating of Residents

Physician

Nurse

Brinkman, 2006

Significant Differences

• Physician > Nurse Rating of Residents– Treat staff with respect– Accept Suggestions– Good team member– Sensitive and empathetic– Respect confidentiality– Honesty and integrety

• Nurse > Physician Rating of Residents– Effectively plan course of care– Anticipate post discharge needs

Brinkman, 2006

Discussion

• Percentages reflect how often the highest item on a 5 point scale was selected

• Parents mean rating for all items was about 57%

• Physician and parents had similar ratings on resident-parent interaction but physicians frequently marked unable to observe

• Parent and nursing staff provide unique perspectives

Brinkman, 2006

Birmingham Children’s Hospital

• Methodology– Independent analysis of doctor-parent-

communication– Surveys of parents and children– Case Series

• Sample– Convenience sample– 51 outpatient visits, 12 doctors

Wasmer, 2004

Birmingham Children’s Hospital

Percent of Contribution to Visit by Time

67%

28%

5%

Doctor

Patient

Child

Wasmer, 2004

Birmingham Children’s Hospital

Percent of Contribution to Visit by Turn

52%

38%

10%

Doctor

Patient

Child

Wasmer, 2004

Discussion/Conclusions

• Growing evidence that children should participate in clinical encounters including shared decision making

• Most research indicates very low communication by children

Wasmer, 2004

Active Listening Skills

• Attentive body language– Posture and gestures showing involvement

and engagement– Appropriate body movement– Appropriate facial expressions– Appropriate eye contact– Non-distracting environment

Robertson, 2005

Active Listening Skills

• Following skills (Giving the speaker space to tell their story in their own way)– Interested ‘door openers’– Minimal verbal encouragers– Infrequent, timely and considered questions– Attentive silences

Robertson, 2005

Active Listening Skills

• Reflecting skills (Restating the feeling and/or content with understanding and acceptance)– Paraphrase (check periodically that you’ve

understood)– Reflect back feelings and content– Summarize the major issues

Robertson, 2005

Communication Styles

• Direct– Meaning is conveyed through explicit statements

made directly to the people involved. No need to rely on contextual factors such as situation and timing.

• Indirect– Meaning is conveyed by suggestion, implication,

nonverbal behavior or other contextual cues. This allows one to avoid confronting another person or cause them to lose face.

Foreign Affairs Canada and International Trade Canada, 2007

Communication Styles

• Linear– Discussion is conducted in a straight line,

almost like an outline. There is a low reliance on context.

• Circular – Discussion is conducted in a circular manner.

The main point is often left unstated. There is a high reliance on context.

Foreign Affairs Canada and International Trade Canada, 2007

Communication Styles

• Attached– Issues are discussed with feeling and

emotion.

• Detached– Issues are discussed with calmness and

objectivity, conveying the speaker’s ability to weigh all the factors impersonally.

Foreign Affairs Canada and International Trade Canada, 2007

Communication Styles

• Intellectual Engagement– Any disagreement with ideas is stated directly, with

the assumption that only the idea, not the relationship, is being attached. (We’re just having a friendly discussion – don’t take it personally’.)

• Relational Confrontation– Relational issues and problems are confronted

directly, while intellectual disagreement is handled more subtly and indirectly.

Foreign Affairs Canada and International Trade Canada, 2007

Communication Styles

• Concrete (Factual)– Issues are best understood through stories,

metaphors and examples, with an emphasis on the specific, rather than the general.

• Abstract (Big Picture)– Issues are best understood through theories,

principles and data, with emphasis on the general, rather than the specific.

Foreign Affairs Canada and International Trade Canada, 2007

Communication Style Activity

Why Conduct a Culturally Competent History

• Increasing diversity of U.S. population• Importance of health belief

– Diagnosis– Compliance– Traditional Treatments

• Importance of history in diagnosis and decisions about diagnostic and therapeutic options

Culturally Competent Care

• Recognizes the complexity of cultural influences

• Issue specific not culture specific • Takes advantage of epidemiology but

creates a uniform approach to any person• Learn about culture but avoid stereotyping

Parallels with “Discipline” Specific History

• Pediatrics– Developmental Stages– Caregivers vs. Patient– Wide belief in traditional health practices

• Feeding• Discipline• Crying Infant• Disease Susceptibility

Culturally Competent History

• Greeting– Respectful– Addresses formally (Mr., Mrs.)

• Why they came to see the physician

• Health beliefs regarding the illness– Kleinman’s questions

Culturally Competent History

• Avoid showing reaction or making judgments about patient’s beliefs– Avoid judgmental or condescending

statements– Neutral facial expression– Avoid making assumptions– Avoid alienating or emotionally laden terms

Culturally Competent History

• Inquire about medical decision making authority

• Use lay terms

• Show empathy

• Ask final question: “Is there anything else I can help you with or any other questions that you have?”

Questions

1. What do you thinks caused your problem?

2. Why do you think it started when it did?3. What do you think your sickness does to

you? How does it work?4. How severe is you sickness? Will I have

a short or a long course?

Questions?

5. What kind of treatment do you think that you should receive?

6. What are the most important results you hope to receive from this treatment?

7. What are the chief problems your sickness has caused you?

8. What do you fear most about your sickness?

Cultural History Activity

References• Boyd SD. Using active listening: improve your

communication skill with the most powerful tool available. Nurs Manage. 1998;29(7):55.

• Brinkman WB, Geraghty SR, Lanphear BP, Khourey JC, et al. Evaluation of resident communication skills and professionalism: a matter of perspective. Pediatrics. 2006;118(4):1371-1379.

• Carrillo, J. E., Green, A. R. & Betancourt, J. R. Cross cultural primary care: A patient based Approach. Ann Intern Med. 1999;130: 829-834.

References• Foreign Affairs Canada and International Trade

Canada. Virtual Campus: Independent Learning Module on International Work Skills. Cross-Cultural Skills. Available at: http://www.dfait-maeci.gc.ca/ypi-jpi/pdf/Cross-Cultural_Skills-en.pdf Accessed March 27, 2007

• Kleinman A, Eisenberg L, Good G. Culture, illness and care: Clinical lessons from anthropologic and cross-cultural research. Ann Intern Med. 1978;88: 251-258.

• Kreps G, Kunimoto E. Effective communication in multicultural heath care settings. Thousand Oaks, CA: Sage Publications; 1994.

References• Robertson K . Active listening: more than just paying

attention. Australian Fam Phys. 2005;34(12):1053-1055.

• Spector R. Cultural Diversity in Health and Illness. 5th ed. Upper Saddle River, NJ: Appleton and Lange; 2000.

• Wasmer E, Minnaar G, Abdel Aal N, Atkinson AM et al. How do peadiatricians communicate with children and parents? Acta Paeditrica. 2004;93:1501-1506.

Questions