ivms icm- communication skills in clinical medicine

Marc Imhotep Cray, M.D.

Communication Skills In Clinical Medicine

Prepared and presented by Marc Imhotep Cray, M.D.

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Communication Matters!

Communication impacts:

Diagnosis

Adherence

Patient satisfaction

Physician satisfaction

Malpractice litigation

2


In Fact...

According to defense attorneys, communication

breakdown is the most important event

leading to a patient's decision to litigate.

35% Physician communication

35% Physician attitude

10% Patient financial incentives

20% Other

3

Physician scores on a national clinical skills examination as predictors of complaints to medical regulatory authorities. JAMA. 2007 Sep 5;298(9):993-1001.

http://www.ncbi.nlm.nih.gov/pubmed/17785644



Communication is Not

"Just Talking"

Communication is the most commonly used

medical procedure

Communication skills are not innate or fixed

Communication skills can be learned and

improved

Physicians can improve health outcomes by

learning how and when to use specific

communication techniques

4

Richards T. Chasms in communication.

BMJ. 1990 December 22; 301(6766): 1407–1408.

PMCID: PMC1679819

http://www.ncbi.nlm.nih.gov/portal/utils/pageresolver.fcgi?recordid=1382239759429701



Physician Tasks- The Two Fs

Biomedical Tasks

Find it!

Fix it!

5


Physician Tasks :

The Four Es

Communication Tasks

Engage the patient!

Empathize with the patient!

Educate the patient!

Enlist the patient in his/her own health care!

6

Poor Communication Between Doctors Costs Patients’

Lives, Apr 30, 2013

www.thedoctorschannel.com/view/poor-communication-

between-doctor

http://www.thedoctorschannel.com/view/poor-communication-between-doctor








The First E - Engagement

Is the interview an inquiry

or an inquisition?

Who is in charge of the

inquiry process?

What does interruption say

about roles?

How many complaints are

"normal?"

7

Clarke AR, Goddu AP et.al. Med Care. 2013 Nov;51(11):1020-6.

Thirty years of disparities intervention research: what are we doing to close racial and ethnic gaps in health care? doi: 10.1097/MLR.0b013e3182a97ba3.




Agree Upon an Agenda for the Visit

Ask - "Is there anything else you would

like to talk about?"

Ask - "Is there anything else you were

wondering about?"

Ask - "What were you hoping we'd

accomplish today?"

8


Pay Attention to Two "Voices"

Physicians have a "voice," the voice of medicine.

This voice...

Wants to obtain a history.

Asks close-ended questions to get "facts"

Constructs a differential

diagnosis.

Patients have a voice, the voice of experience.

This voice...

Wants to tell the "story" of the illness

Is concerned with the personal meaning of the illness.

Speaks in response to openended questions

9


Translate, Bridge, Funnel

Translate - Converse in one "voice"

while thinking in another

Bridge - Acknowledge when topics are

being changed and give the reasons for

the changes

Funnel - Direct the flow of conversation

by asking for information about topics of

specific concern

10


Outcomes of Successful Engagement(1)

Develop a more accurate

diagnosis

Obtain more information

about the illness.

Understand the effect of

the illness upon the

patient.

Increase the likelihood of

adherence

Establish an improved

physician-patient

relationship.

Discover the health

belief system of the

patient

11


Outcomes of Successful Engagement(2)

Establish an effective relationship

Create an opportunity for partnership.

Demonstrate interest in the patient's

point of view

Provide the patient with an opportunity

to tell their story

12


The Second E - Empathy

Being Seen

Being Heard

Being Accepted

13

Flickr | caroline_1


Being Seen Techniques

N.B. See new patients with their clothes on at

the beginning of the interview

"See" the patient - acknowledge...

Facial and bodily expressions of feelings.

Mode of dress and physical presentation.

Notable physical characteristics.

Eliminate physical barriers - desks, charts, etc.

14


Being Heard Techniques

Use the language of the patient.

Give feedback to the patient.

Ask for feedback from the patient.

Invite the patient to tell his/her story;

welcome the story:

Feelings

Values

Thoughts

15


But There's a Problem...

Physicians acquire more than

13,000 new words during

their training.

They use them with patients

Adapt to the patient's "voice"

(language, beliefs, etc.).

This requires concentration

16


Being Accepted Techniques

If you must judge, judge the behavior not

the person.

Communicate your understanding of the

patient's feelings and values (do so in a

way that they can correct you).

Use appropriate self-disclosure

17


Steps in Communicating Empathy

Recognize the emotional moment

Pause to question: "What's going on here?"

Name the emotion you believe is present.

Communicate your understanding of the

emotion and validate its presence

Respect the patient's efforts with the emotion

Offer support and partnership

18


Outcomes of Establishing an

Empathic Connection

Reduced anxiety related to isolation or

abandonment.

Improve adherence.

Increased level of connection:

1) Increased patient satisfaction.

2) Increased physician satisfaction.

Reduced physician frustration

19


The Third E - Education

Assume the following

questions and answer

them as a matter of

course:

What has happened to me?

Why has it happened to me?

What is going to happen to

me?

20

Can Doctors Really Educate Patients in 15 Minutes? Aug 17, 2012 http://www.thedoctorschannel.com/view/can-doctors-really-educate-patients-in-15-mins/

http://www.thedoctorschannel.com/view/can-doctors-really-educate-patients-in-15-mins/
















Mysteries of the Medical World

What are you (they) doing for me (to me)?

Why are you (they) doing this rather than that?

Will it hurt me or harm me? How much? How long?

When and how will you know what all this (tests, procedures, etc.) means?

21


Patient Survey(1)

In a telephone survey of 1000 randomly

selected adults:

25% reported they had stopped seeing

a physician at some time because of

communication problems

60% reported they wanted physicians to

do a better job explaining options

22

Patient-physician communication: why and how.

J Am Osteopath Assoc. 2005 Jan;105(1):13-8.





Patient Survey (2)

50% said, "Ask if the patient has more

questions."

48% said, "Ensure the patient understands

what the physician has said."

47% said, "Explain what the physician is

doing."

23


The Fourth E - Enlistment

The challenge is to enlist the patient as an

active decision maker and participant in

her/his health care.

Active decision making can not be assumed

Adherence can not be assumed.

Physician action influences both

participation and adherence

24


The Price of Failure

Patients do not adhere to physicians'

recommendations at least 30% of the time

Non-adherence with prophylactic

medication among asymptomatic patients

can be more than 50%

25


What's Going On?!?

3 billion new prescriptions

are written in U.S. each

year

Up to 50% will never be

filled or taken

Up to 50% of those filled

will only be partially taken

26

Generation Rx How prescription drugs are altering American lives, minds, and body J Clin Invest. 2006 February 1; 116(2): 287. doi: 10.1172/JCI27774 Americans Skimping on Medication, Sep 14, 2012 http://www.thedoctorschannel.com/view/americans-skimping-on-medication/



http://www.thedoctorschannel.com/view/americans-skimping-on-medication/








American Prescription Drug Use

27

Generation Rx How prescription drugs are altering American lives, minds, and body J Clin Invest. 2006 February 1; 116(2): 287.

“The average number of prescriptions drugs per person, annually, in 1993 was seven The average number of prescriptions drugs per person, annually, in 2000 was eleven The average number of prescriptions drugs per person, annually, in 2004 was twelve”




The Poor Adherence Myth

Myth - "Poor adherence can be attributed to

patient characteristics."

In fact, no consistent relationship has been shown

between adherence and...

Age

Gender

Social economic status

Marital status

Personality traits (introverted, gregarious, etc.)

28


Factors Affecting Adherence

The objective severity of the disease does

not affect adherence;

what the physician believes has limited impact

The subjective perception of the

seriousness of the disorder does affect

adherence;

what the patient believes is critical

29


What Does Affect Adherence?

The patient's perception of the seriousness

of the disease

The patient's perception of the efficacy of

the treatment

The duration of the treatment and the illness

The complexity of the regimen

The relationship with the physician

30


Enlistment Techniques

To improve adherence physicians must:

Demonstrate compassion

Communicate:

Personal concern for the patient.

Personal interest in the patient's future well-

being

Activate patient motivation

Share responsibility with the patient

31


Assume a Self Diagnosis

The patient has an internal belief system

which explains to the patient what is

happening with his or her health

This includes

cause of a health problem,

meaning (consequences and symbolism) of

the problem, and

how the problem might be resolved

32


To Improve Adherence, the

Physician Must Be Willing to...

Discover the patient's beliefs:

“cause, meaning and cure”

Discuss the patient's beliefs

33


Enlistment Technique

Ask - "This is what I think is

going on.

(State your explanation.)

How does my explanation fit

with what you have been

considering?"

34

Walker J, Leveille SG et.al. Inviting patients to read their doctors' notes: patients and doctors look ahead: patient and physician surveys. Ann Intern Med. 2011 Dec 20;155(12):811-9.





Outcomes of Enlistment

Increased likelihood of adherence.

Empowerment of the patient: motivation.

Greater range of choices for physician

and patient.

Partnership between physician and

patient.

Increased patient and physician

satisfaction

35


There is a Need to End-

How to Disengage

Summarize diagnosis, treatment,

and prognosis

Review next steps:

Future visits, phone calls, etc.

Tests, referrals, etc.

Say good-bye, express hope

36


Selected References

37

PubMed A communication skills course for preclinical students: evaluation of general practice based

teaching using group methods.

Kendrick T, Freeling P. Med Educ. 1993 May;27(3):211-7.


Effects of communication skills training on students' diagnostic efficiency.

Evans BJ, Stanley RO, Mestrovic R, Rose L. Med Educ. 1991 Nov;25(6):517-26.


Teaching communication skills: a skills-based approach. Wagner PJ, Lentz L, Heslop SD.Acad

Med. 2002 Nov;77(11):1164.


Simpson M, Buckman R, Stewart M, Maguire P, Lipkin M, Novack D, Till J. Doctor-patient

communication: the Toronto consensus statement.

BMJ. 1991 Nov 30;303(6814):1385–1387.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1671610/

Kerr DN. Teaching communication skills in postgraduate medical education.

J R Soc Med. 1986 Oct;79(10):575–580.








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