Communication Skills In Clinical Medicine

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

Marc Imhotep Cray, M.D.

Communication Matters!
Communication impacts:

Diagnosis Adherence Patient satisfaction Physician satisfaction Malpractice litigation

Marc Imhotep Cray, M.D.

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.

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
Richards T. Chasms in communication. BMJ. 1990 December 22; 301(6766): 14071408. PMCID: PMC1679819

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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-communicationbetween-doctor

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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?"

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.

Marc Imhotep Cray, M.D.

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?"

Marc Imhotep Cray, M.D.

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

Marc Imhotep Cray, M.D.

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
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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. 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

Flickr | caroline_1

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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.

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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 the patient to tell his/her story; welcome the story: Feelings Values Thoughts
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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

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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

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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

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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
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Marc Imhotep Cray, M.D.

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-doctors-reallyeducate-patients-in-15-mins/

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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?

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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
Patient-physician communication: why and how. J Am Osteopath Assoc. 2005 Jan;105(1):13-8.

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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."

Marc Imhotep Cray, M.D.

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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

Marc Imhotep Cray, M.D.

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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%

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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

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

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;

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

Marc Imhotep Cray, M.D.

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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

Marc Imhotep Cray, M.D.

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

Personal concern for the patient. Personal interest in the patient's future wellbeing

Activate patient motivation Share responsibility with the patient

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Marc Imhotep Cray, M.D.

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

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

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

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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?"

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.

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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

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: Future visits, phone calls, etc. Tests, referrals, etc. Say good-bye, express hope

Marc Imhotep Cray, M.D.

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Selected References
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. http://www.ncbi.nlm.nih.gov/pubmed/8336570 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. http://www.ncbi.nlm.nih.gov/pubmed/1758333 Teaching communication skills: a skills-based approach. Wagner PJ, Lentz L, Heslop SD.Acad Med. 2002 Nov;77(11):1164. http://www.ncbi.nlm.nih.gov/pubmed/12431944 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):13851387. 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):575580. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1290495/
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THE END, THANK YOU FOR YOUR ATTENTION

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