Physician communication skills in clinical medicine

Communication Skills In Clinical Medicine

Companions: eNotes: Fundamental Communication Skills and the Doctor Patient Relationship.pdf Articles: Travaline et al. Patient-Physician Communication: Why and How. J Am Osteopath Assoc. 2005 Jan;105(1):13-8.

Marc Imhotep Cray, M.D.

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

Communication Matters!

Communication impacts:     

Diagnosis Adherence Patient satisfaction Physician satisfaction Malpractice litigation

Marc Imhotep Cray, M.D.

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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 Physician scores on a national clinical skills examination as predictors of complaints to medical regulatory authorities.

JAMA. 2007 Sep 5;298(9):993-1001.

Marc Imhotep Cray, M.D.

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Communication is Not "Just Talking" 

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Communication is 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

Richards T. Chasms in communication.

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

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Physician Tasks- The Two Fs Biomedical Tasks  Find it!  Fix it!

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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!

Poor Communication Between Doctors Costs Patients’ Lives, Apr 30, 2013 www.thedoctorschannel.com/view/poor-communication-between-doctor

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The First E - Engagement 

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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?"

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?

Marc Imhotep Cray, M.D.

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Agree Upon an Agenda for the Visit 

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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?"

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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.

Marc Imhotep Cray, M.D.

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 open-ended questions

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Translate, Bridge, Funnel 

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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

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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.

Marc Imhotep Cray, M.D.

Increase the likelihood of adherence  Establish an improved physician-patient relationship.  Discover the health belief system of the patient

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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

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The Second E - Empathy   

Being Seen Being Heard Being Accepted

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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.

Marc Imhotep Cray, M.D.

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Being Heard Techniques    

Use the language of the patient.

Give feedback to the patient Ask for feedback from the patient Invite patient to tell his/her story welcome the story:  Feelings  Values  Thoughts

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But There's a Problem... 

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Physicians acquire more than 13,000 new words during their training They use them with patients Adapt to patient's "voice" (language, beliefs, etc.)  This requires concentration

Marc Imhotep Cray, M.D.

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Being Accepted Techniques 

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If you must judge judge behavior not the person Communicate your understanding of patient's feelings and values (do so in a way that they can correct you) Use appropriate self-disclosure

Marc Imhotep Cray, M.D.

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Steps in Communicating Empathy    

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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

Marc Imhotep Cray, M.D.

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Outcomes of Establishing an Empathic Connection 

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Reduced anxiety related to isolation or abandonment Improve adherence Increased level of connection: 1) Increased patient satisfaction 2) Increased physician satisfaction Reduced physician frustration

Marc Imhotep Cray, M.D.

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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?

Can Doctors Really Educate Patients in 15 Minutes?

Aug 17, 2012 http://www.thedoctorschannel.com/view/can-doctorsreally-educate-patients-in-15-mins/ Marc Imhotep Cray, M.D.

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Mysteries of the Medical World  

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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?

Marc Imhotep Cray, M.D.

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Patient Survey (1) In a telephone survey of 1000 randomly selected adults: ď Ž 25% reported they had stopped seeing a physician at some time because of communication problems ď Ž 60% reported they wanted physicians to do a better job explaining options Patient-physician communication: why and how.

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

Marc Imhotep Cray, M.D.

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Patient Survey (2) 

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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."

Marc Imhotep Cray, M.D.

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The Fourth E - Enlistment 

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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

Marc Imhotep Cray, M.D.

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The Price of Failure ď Ž

Patients do not adhere to physicians' recommendations at least 30% of the time

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Non-adherence with prophylactic medication among asymptomatic patients can be more than 50%

Marc Imhotep Cray, M.D.

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What's Going On?!? 

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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

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/ Marc Imhotep Cray, M.D.

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American Prescription Drug Use “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�

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

Marc Imhotep Cray, M.D.

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The Poor Adherence Myth

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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.)

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Factors Affecting Adherence 

The objective severity of the disease does not affect adherence 

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what the physician believes has limited impact

The subjective perception of seriousness of the disorder does affect adherence 

what the patient believes is critical

Marc Imhotep Cray, M.D.

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What Does Affect Adherence? 

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The patient's perception of seriousness of the disease The patient's perception of efficacy of the treatment The duration of treatment and the illness The complexity of regimen The relationship with the physician

Marc Imhotep Cray, M.D.

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Enlistment Techniques To improve adherence physicians must:  Demonstrate compassion  Communicate: 

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Personal concern for the patient Personal interest in patient's future well-being

Activate patient motivation Share responsibility with the patient

Marc Imhotep Cray, M.D.

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“Assume a Self Diagnosis” 

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The patient has an internal belief system which explains to him/her what is happening with his or her health This includes:  

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cause of a health problem meaning (consequences and symbolism) of the problem, and how the problem might be resolved

Marc Imhotep Cray, M.D.

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To Improve Adherence, the Physician Must Be Willing to... 

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Discover the patient's beliefs: “cause, meaning and cure” Discuss the patient's beliefs

Marc Imhotep Cray, M.D.

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Enlistment Technique 

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"This is what I think is going on State your explanation Ask-How does my explanation fit with what you have been considering?"

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.

Marc Imhotep Cray, M.D.

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Outcomes of Enlistment   

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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

Marc Imhotep Cray, M.D.

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There is a Need to EndHow to Disengage Summarize diagnosis, treatment, and prognosis Review next steps:  

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Future visits, phone calls, etc.

Tests, referrals, etc.

Say good-bye, express hope

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THE END

See last slide for further study resources.

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Further Study: Recommended textbook reading: Bickley LS, Szilagyi PG. Chapter 3: Interviewing and the Health History.

In: Bates’ Guide to Physical Examination and History Taking, 10th Ed. LWW, 2009.

Article: Goold SD, Mack Lipkin M. The Doctor–Patient Relationship Challenges, Opportunities, and Strategies. JGIM Volume 14, January (Supplement 1) 1999.

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