Transcript National Advisory Group Meeting

Enhancing Clinician-Patient Communication
for Every Day Practice:
A Workshop on the Four Habits Model of
Clinical Communication
___________________________________________________________________________
21-23 August 2006
A (Brief) Tour of the Four Habits
Introduction
“The patient physician relationship is
the center of medicine. As described
in the patient physician covenant, it
should be ‘a moral enterprise
grounded in a covenant of trust’.
This trust is threatened by the lack
of empathy and compassion that
often accompany an uncritical
reliance on technology and pressing
economic considerations.”
R.M. Glass, JAMA, 1996
THE INFORMED PATIENT
By LAURA LANDRO
Teaching Doctors How to Interview
Programs Offer Strategies For Quickly
Getting to Heart Of Patients'
Problems, Fears
September 21, 2005; Page D5
The Wall Street Journal
THE FOUR HABITS MODEL
___________________________________________________________________________
©1996, 1999, 2003 The Permanente Medical Group, Inc. Physician Education & Development
Revised April 2003 in partnership with the Kaiser Permanente Institute for Culturally Competent Care
The Four Habits of Highly Effective Doctors
___________________________________________________________________________
Habit
Skills
Invest in the Beginning
Create rapport quickly; elicit the patient’s
concerns; let the patient know what to expect
Elicit the Patient’s Perspective Ask for patient’s ideas; determine patient’s
specific request or goal; explore the impact on
patient’s life
Demonstrate Empathy
Be open to the patient’s emotions; make
empathetic statements; convey empathy
nonverbally (pause, touch, facial expression)
Invest in the End
Deliver diagnosis in terms of original concern;
explain rationale for tests and treatments;
summarize visit and review next steps
©1996, 1999, 2003 The Permanente Medical Group, Inc. Physician Education & Development
Revised April 2003 in partnership with the Kaiser Permanente Institute for Culturally Competent Care
FOUR HABITS APPROACH:
HABIT 1:
Invest in the Beginning
“If doctors fail to get at the full
spectrum of concerns in the
beginning of the encounter and to
assess their importance from the
patient's point of view, there is
likely to be more premature
testing, misplaced empathy and
support, and the emergence of
hidden concerns at the end of the
visit.”
FOUR HABITS APPROACH:
HABIT 2
ELICIT THE PATIENT’S
PERSPECTIVE
J U LY 2006
FOUR HABITS APPROACH:
HABIT 3
DEMONSTRATE EMPATHY
FOUR HABITS APPROACH
HABIT 4
INVEST IN THE END
We are what we repeatedly do.
Excellence then, is not an act,
but a habit.
Aristotle
Research Model
___________________________________
Individual
and
Organizational
Characteristics
Health Care
Performance
Outcomes
Essential Attributes of Primary Care
Measured by the Primary Care Assessment Survey (PCAS)
___________________________________________________________________________
Access
Trust
·financial
·organizational
Continuity
Interpersonal
treatment
Clinical
interaction
·longitudinal
·visit-based
Primary
Care
Comprehensiveness
·knowledge of
·communication
·physical exams
Integration
Medical Care. 1998; 36(5):728-739.
patient
·preventive
counseling
Clinician-Patient Relationship Quality
as a Driver of Outcomes

Health Outcomes
 Adherence
 Symptom Relief
 Clinical Improvement

Business Outcomes
 Loyalty to the practice
 Willingness to recommend
 Malpractice risk
Relationship Quality Index from the Primary Care
Assessment Survey (PCAS)
Interpersonal
treatment
Trust
Relationship
Quality
Communication
Whole-Person
Orientation
Relationship Between Trust and Disenrollment
1996
Trust ___________________________________________________________________________
(percentile)
95th
11.4%
75th
14.9%
50th
19.2%
25th
24.3%
37.1%
5th
0
10
20
30
% Voluntary Disenrollment
Source: Safran et al. JFP 2001; 50:130-136.
40
50
Patient Trust as a Predictor of Adherence:
Successful Behavior Change
1996 Trust
Scale ___________________________________________________________________________
(percentile)
95th
32.9%
75th
31.7%
50th
29.9
%
25th
28.0%
5th
24.3%
0
20
25
30
% Successful Change
Source: Safran et al. JGIM 2000; 15 (supp):116.
35
Cost-Related Non-Compliance by Quality of
Physician-Patient Relationship
Percent Report Cost-Related
Non-Compliance
___________________________________________________________________________
20
18
16
14
12
10
8
6
4
2
0
15%
8%
7%
Lowest
6%
Highest
MD-Patient Relationship Quality
Source: Wilson et. al., SGIM 2001
Effect of a Patient Involvement Intervention on
Diabetes Control
Experimental Group
Control Group
14
12
10.59
10.61
10.26
10
9.06 *
8
6
4
2
0
Glycosylated HbA1 (%)
Pre-Intervention
Greenfield, S., et al. J Gen Intern Med, 1988; 3:448-457
Glycosylated HbA1 (%)
Post-Intervention
* p<0.001
Effects of an Intervention on Health-related Quality of Life:
Functional Limitations
Mobility (scored 0 3)
2
Physical (scored 0 5)
3
Experimental Group
Experimental Group
Control Group
Control Group
2.5
2.25
1.5
1.89
2
1.11
1
1.5
1.41
0.85
0.98 *
1
0.5
0.39
0.19 *
0
0.5
0
Pre-Intervention
Post-Intervention
Greenfield, S., et al. J Gen Intern Med, 1988; 3:448-457
Pre-Intervention
Post-Intervention
* p<0.01
Patient Preference for Active Involvement in Medical
Decision-Making: Effect of a Patient Involvement Intervention
Experimental Group
Control Group
30
24.3*
25
20
19.4
19.2
18.7
15
10
5
0
Pre-Intervention
Greenfield, S., et al. Annals of Internal Medicine, 1985; 102:520-528
Post-Intervention
* p<0.001
Effects of an Intervention on Patient Involvement in the
Physician-Patient Interaction
4
Number of controlling behaviors by
patient (including questions,
interruptions & directions)
Effectiveness of patient
information seeking
2
Experimental Group
Experimental Group
Control Group
Control Group
3
1.5
2.72 *
2
1.38 *
1
0.82
1
0.76
0.8
0.5
0.83
0.6
0.55
0
0
Pre-Intervention
Post-Intervention
Greenfield, S., et al. J Gen Intern Med, 1988; 3:448-457
Pre-Intervention
Post-Intervention
* p<0.05
What Drives Patients’ Willingness To Recommend
And How Are We Doing (2002)
Percentile Rank Adjusted
100
80
Office Staff
60
Clinical Team
Relationship Duration
40
Integration
Health
Promotion
Visit-based Continuity
20
Organizational
Access
Interpersonal Treatment
Knowledge
of Patient
Patient Trust
Communication
Priority Improvements
0
0
0.2
0.4
0.6
0.8
Correlation to Measure of Willingness to Recommend
1
Number of Utterances per 15
minute visit
Relationship Between Physician
Communication and Medical Malpractice Risk
25
20
15
19.4
14.5
11.9
11.2
Facilitation
Orientation
10
5
0
Physician Communication Processes
Source: Levinson et al. JAMA 1997; 277:553-559.
No Claims
Claims
Primary Care Relationship Quality &
Interactions, 1996-1999
___________________________________________________________________________
p < .001
Communication -1.51
Interpersonal
-2.06
Treatment
p < .001
1.11 p < .01
Knowledge of Patient
Physical
exams
-2.97
p < .001
Trust
-4
-3
-2
-0.68
-1
p < .01
0
Observed Change in Score
Source: Murphy et al. JFP 2001.
1
2
Changing Rates of Preventive Care Processes,
1996-2001
100.0
Diabetes Eye
Exams
80.0
Cervical
Cancer
Screening
60.0
Breast Cancer
Screening
40.0
Adolescent
Hep B
Immunization
20.0
Beta Blocker
Treatment
Following a
Heart Attack
HEDIS did not begin testing adolescent
Hepatitis B immunization rates until 1997
0.0
1996
1997
1998
1999
2000
2001
2002
FOUR HABITS APPROACH:
HABIT 1:
Invest in the Beginning
Habit 1: Invest in the Beginning
___________________________________________________________________________
Skills
Technique and Examples
Create rapport quickly
Introduce
self to everyone in the room
Refer to patient by last name and Mr. or Ms.
until a relationship has been established
Acknowledge wait
Make a social comment or ask a non-medical
question to put the patient at ease
Convey knowledge of patient's history by
commenting on prior visit or problem
Consider patient’s cultural background and use
appropriate XXXX, eye contact, and body
language
Habit 1: Invest in the Beginning
___________________________________________________________________________
Skills
Technique and Examples
Elicit the patient’s
concerns
Start
Plan the visit with the
patient
Repeat
with open-ended questions:
“What would you like help with today?”
“I understand that you’re here for … Could you
tell me more about that?
Speak directly with patient when using an
interpreter
concerns back to check understanding
Let patient know what to expect: “How about if
we start with talking more about … then I’ll do
an exam, and then we’ll go over possible
test/ways to treat this? Sound OK?”
Prioritize when necessary: “Let’s make sure we
talk about X and Y. It sounds like you also want
to make sure we cover Z. If we can’t get to the
other concerns, let’s …”
Habit 1: Invest in the Beginning
___________________________________________________________________________
Payoffs
Establishes
a welcoming atmosphere
Allows faster access to real reason for visit
Increases diagnostic accuracy
Requires less work
Minimizes “Oh by the way … “ at the end of visit
Facilitates negotiating an agenda
Decreases potential for conflict
Interrupted Opening
Dr.:
Pt.:
Dr.:
Pt.:
Dr.:
Pt.:
Dr.:
Pt.:
Dr.:
Pt.:
Dr.:
Pt.:
Dr.:
Pt.:
Hello Ms. Jones. What problems are you having?
I have chest pain.
When did it begin? [Interruption via closed ended
question]
It started about three months ago.
Can you tell me more about it?
It’s a gnawing pain that hurts in the center of my
chest.
Does the pain go into your arms or to your neck?
Yes.
Is it worse when you get excited?
Yes.
Do you smoke cigarettes?
Yes.
Are you currently taking any medication?
No.
Completed Opening
Dr.:
Pt.:
Dr.:
Pt.
Dr.:
Pt.:
Dr.:
Pt.:
Dr.:
Pt.:
Dr.:
Pt.:
Hello Mrs. Jones. What problems are you having?
I’m having chest pain.
uh-huh. [Continuer]
It’s a gnawing pain.
uh-huh. [Continuer]
It starts in my chest and goes to my arm and jaw.
(silence) [Continuer]
It’s really frightening.
I see. [Acknowledgment]
You know, my father died from a heart attack and I’m
afraid that the same thing may happen to me.
I can see that you’re concerned, and I’ll certainly talk
with you more about your chest pain. Before we
start, however, is there anything else that’s
concerning you that I need to know about?
No.
1. Facilitating the Opening of the Interview
Table 1. Relationship Between Interruption and Elapsed Time for 52
Interrupted Opening Statements.
Concerns Expressed
Before Interruption
Encounters
=...........................…
0
1
2
3
4
Mean Time to
Interruption
n .................................< s
6
6.83
28
16.48
8
25.00
7
37.50
3
37.00
Beckman and Frankel, Ann Int Med 1984
FOUR HABITS APPROACH:
HABIT 2
ELICIT THE PATIENT’S
PERSPECTIVE
Habit 2: Elicit the Patient’s Perspective
___________________________________________________________________________
Skills
Technique and Examples
Ask for the patient’s
ideas
Assess
Elicit specific request
Determine
Explore the impact on
the patient’s life
Check
patient’s point of view:
“What do you think might be causing your
problem?”
“What worries or concerns you most about this
problem?”
“What have you don’t to treat your illness so
far?”
Ask about ideas from loved ones or from
community
patient’s goal in seeking care: “How
were you hoping I could help?”
context: “How has the illness affected
your daily activities/work/family?”
Habit
2:
Elicit
the
Patient’s
Perspective
___________________________________________________________________________
Payoffs
Respects
diversity
Uncovers hidden concerns and diagnostic clues
Reveals use of alternative treatments or requests for
tests
Improves diagnosis of depression and anxiety
Habit 2: Elicit the Patient’s
Perspective
 Condition:
qaug dab peg
 English translation:The Spirit Catches
You and You Fall down
 Medical translation: Epilepsy
From the Medical Record
 “History
of present illness: The patient is an 8
month, Hmong female whose family brought
her to the emergency room after they had
noticed her shaking and not breathing well for
a 20 minute period of time. According to the
family the patient has had multiple like
episodes in the past, but have never been
able to communicate this to emergency room
doctors on previous visits secondary to a
language barrier.”
What is wrong with Lia and what
should be done?


Doctors’ explanatory model: Epilepsy is a sporadic
malfunction of the brain during which neural impulses
fire in a chaotic rather than orderly pattern. Surgery
would be dangerous; anti-convulsive drugs are
recommended.
Family’s explanatory model:Qaug dab peg means
that the child is imbued with spirits, which is as much
an honor as an illness. Therefore, it is unclear
whether these symptoms should be strongly
discouraged, and if so, the wearing of amulets is
recommended.
Question:How many of the 40+
health care professionals who
treated Lia were aware of the Lee
family’s beliefs?
 Answer:
One.
 Reason: She was the only one who
asked.
Habit 2 forms the basis of
physician-patient collaboration
 Ask
for the patient’s ideas
 What
do you think is causing the problem?
 What about this problem concerns you the most?
 Identify
 What
the patient’s goals for the visit.
do you hope we can accomplish today?
 Explore

the impact on the patient.
How has this affected you?
 Does this keep you from living your life as you
usually do?
Questions:
 What
 What
happens when you do this well?
happens when this habit is
overlooked or done poorly?
FOUR HABITS APPROACH:
HABIT 3
DEMONSTRATE EMPATHY
Habit 3: Demonstrate Empathy
___________________________________________________________________________
Skills
Technique and Examples
Be open to the patient’s
emotions
Respond
Make an empathic
statement
Look
Convey empathy
nonverbally
Use
in a culturally appropriate manner to
changes in body language and voice tone
for opportunities to use brief empathic
comments: “You seem really worried.”
Compliment patient on efforts to address
problem
a pause, touch, or facial expression
Habit 3: Demonstrate Empathy
___________________________________________________________________________
Payoffs
Adds
depth and meaning to the visit
Builds trust, leading to better diagnostic information,
adherence, and outcomes
Makes limit-setting or saying “no” easier
A Doctor’s Story – 25 Years Later
Twenty five years ago when I was a 3rd year student
and in the ER, a family including a 10 year old girl
and her grandparents came in badly burned… The
girl was in arrest and despite all our efforts died. I
still remember the smell of charred flesh; it was
overpowering. I was sent to ask the mother for an
autopsy. Instead of beginning by informing her of
the death I began with, “Sorry to bother you at this
time but…” and then asked her my question. She
screamed and collapsed, hysterical at my feet. I
was aghast, guilty, stunned, felt inadequate to make
any appropriate response. I still feel awful about it
to this today.
Three Questions to Ponder?
 What
feelings does this story evoke
in you? About the mother? About
the physician? About the situation?
 What would you do in this situation?
 What would you want to say to this
physician after he told his story?
Early to mid- 20th Century Focus on
Objectivity
 Aring:
physicians must remain apart
from “the enervating morass of the
patient’s problems, viewing them
detachedly yet interestedly.” JAMA 1958
 Blumgart:
“neutral empathy;”
Detachment is necessary to
accurately observe and predict
patients’ emotional states. NEJM 1964
The “Value” of Detached Concern
 Fox
and Lief: “The same detachment
that enables medical students to
dissect a cadaver without fear or
disgust seemingly enables them to
listen to patients without becoming
emotionally involved”.
Lief & Lief, eds. The Psychological Basis of
Medical Practice, 1963
The Appeal of Detachment
Detachment was mistakenly equated
with:
Objective diagnoses
Effectiveness
Less burn-out
Late 20th; Early 21st Century Views are More
Evidence-Based
“Keeping considerations of self and professional
together permits us to see work as an expression
of self, and professional aspirations for
trustworthiness and virtuous action as
aspirations of our own heart. In a field that
demands as much of us as medicine, anything
less than this integration of person and
professional may be unsupportable in the long
run.”
Inui, 2003
The Changing Role of Empathy
in Medical Care
Until recently, physicians were
taught to view their own feelings,
emotions and relationships with
patients as barriers to making good
“objective” decisions.
Empathy Makes A Difference:
The Evidence
Empathy & emotional engagement are
equated with:
More thorough diagnoses

Suchman, Markakis, Beckman, Frankel, JAMA,
1997 (USA)
Adherence

Kim, Kaplowitz, Johnston Eval Health Prof 2004
(Korea)
Satisfaction

& trust
Shields, Epstein, Franks etal (2005)
Zachariae et al (2003)
 454
cancer patients & 31 physicians at an
oncology outpatient clinic, Aarhus University
Hospital, Denmark
 Measured many aspects of dr-patient
relationship
 Empathy, as perceived by the patient,
predicts satisfaction even after controlling for
disease severity, sociodemographic factors,
self-efficacy and prior distress
 Greater empathy associated with decreased
post-visit distress post-visit (after controls)
 Empathy associated with greater diseaserelated self-efficacy
Breaking Bad News
 It
is all too common in the life of a
physician
 Physicians typically have little if any
training in it
 It often makes physicians, even
experienced ones, uncomfortable
 It is done poorly more often than not
Styles of Delivery (Friederichsen,
Strang, & Carlsen, 2000) 30
patients admitted to a hospitalbased home care unit
(Uppsala, Sweden)
 The
inexperienced messenger
 The emotionally burdened expert
 The rough and ready expert
 The distanced doctor
 The benevolent but tactless expert
 The empathic professional
Delivering Bad News
Empathically: Some Guidelines
 Find
out what the patient knows already
 Find out what the patient wants to know
 Share the information simply and honestly
 Give patient time to absorb the news
 Acknowledge the patient’s emotions
 Name,
legitimize, and support any emotions
 Offer appropriate reassurance, but not false hope
 Make
plans for follow-up, short and long-term
 Assess
support of family, friends, spiritual beliefs-involve loved ones
FOUR HABITS APPROACH
HABIT 4
INVEST IN THE END
Habit 4: Invest in the End
___________________________________________________________________________
Skills
Technique and Examples
Deliver diagnostic
information
Frame
Provide education
Explain
diagnosis in terms of patient’s original
concerns
rationale for tests and treatments
Review possible side effects and expected
course of recovery
Discuss options that are consistent with
patient’s lifestyle, cultural values and beliefs
Provide resources (e.g., written materials) in
patient’s preferred language when possible
Habit 4: Invest in the End
___________________________________________________________________________
Skills
Technique and Examples
Involve the patient in
making decisions
Discuss
treatment goals: express respect
towards alternative healing practices
Assess patient’s ability and motivation to carry
out plan
Explore barriers: “What do you think we could
do to help overcome any problems you might
have with the treatment plan?”
Test comprehension by asking patient to repeat
instructions
Set limits respectfully: “I can understand how
getting that test makes sense to you. From my
point of view, since the results won’t help us
diagnose or treat your symptoms, I suggest we
consider this instead.”
Habit 4: Invest in the End
___________________________________________________________________________
Skills
Technique and Examples
Complete the visit
Summarize
visit and review next steps
Ask for additional questions: “What questions
do you have?”
Assess satisfaction: ” Did you get what you
needed?”
Close visit in a positive way: “It’s been nice
meeting you. Thanks for coming in.”
Habit 4: Invest in the End
___________________________________________________________________________
Payoffs
Increases
potential for collaboration
Influences health outcomes
Improves adherence
Reduces return calls and visits
Encourages self care
PATIENT ADHERENCE TO MEDICATION REGIMEN OVER TIME
___________________________________________________________________________
Nonadherence Due to Cost (2003)
___________________________________________________________________________
18%
Didn't fill Rx 1+
times
16%
Skipped doses
28%
26%
25%
23%
22%
22%
12%
Took smaller
doses
18%
18%
19%
26%
Any cost-related
nonadherence
Total
No Rx Coverage
Source: Safran et al. Health Affairs April 2005.
Low income
37%
35%
35%
Complex chronic
Rates of Cost- and Experience-Related Non-Adherence
by Chronic Condition and Coverage Status
___________________________________________________________________________
Seniors with Coverage
Seniors without Coverage
Cost-Related Non-Adherence (%)
50.3%
50.0%
Experience-Related Non-Adherence (%)
49.0%
51.9%
50.0%
41.8%
40.5%
40.0%
hr
on
ic
on
C
x
pl
e
om
C
x
pl
e
om
C
C
on
ns
i
rt
e
yp
e
H
D
ia
b
HF
C
Source: Safran et al. Health Affairs April 2005.
et
es
0.0%
ia
b
0.0%
D
10.0%
HF
10.0%
hr
on
ic
20.0%
et
es
20.0%
25.5%
ns
i
30.0%
24.4%
31.5%
29.8%
rt
e
26.3%
25.1%
C
30.0%
29.8%
25.9%
28.9%
yp
e
30.0%
34.8%
H
40.0%
Rates of Nonadherence By Coverage Status,
Poverty, and Disease Burden (2003)
___________________________________________________________________________
26%
Nonadherence due
to cost
37%
35%
35%
25%
27%
28%
Nonadherence due
to experiences
Nonadherence due
to self-assessed
need
15%
18%
17%
19%
40%
Total: Any
Nonadherence
Total
No Rx Coverage
Source: Safran et al. Health Affairs April 2005.
34%
48%
48%
52%
Low income
Complex chronic
PATIENT TRUST AS A PREDICTOR OF ADHERENCE:
1996 Trust
ATTEMPTED BEHAVIOR CHANGE
Scale ___________________________________________________________________________
(percentile)
95th
87.8%
75th
85.5%
50th
81.9%
25th
78.4%
71.3%
5th
0
70
75
80
85
% Attempted Change
Source: Safran et al. JGIM 2000; 15 (supp):116.
90
95
100
PATIENT TRUST AS A PREDICTOR OF ADHERENCE:
SUCCESSFUL BEHAVIOR CHANGE
1996 Trust
Scale ___________________________________________________________________________
(percentile)
95th
32.9%
75th
31.7%
50th
29.9
%
25th
28.0%
5th
24.3%
0
20
25
30
% Successful Change
Source: Safran et al. JGIM 2000; 15 (supp):116.
35
MANAGING YOUR DIABETES CARE
In the last 6 months, did your [fill in] talk
with you about specific things you could
do to keep your diabetes under good
control?
100
95 %
91 %
Personal Doctor
In the last 6 months, did your [fill in] give
you as much information about
managing your diabetes as you needed?
100
Nurse, NP, PA
96 %
91 %
Personal Doctor
Nurse, NP, PA
80
80
60
60
40
40
20
20
9%
9%
5%
4%
0% 0 %
0
0% 0%
0
Yes, definitely Yes, somewhat
No
Yes, definitely Yes, somewhat
No
MANAGING YOUR DIABETES CARE
Do you need more help from your health care providers in any of the following areas
in order to keep your diabetes under good control?
100
80
60
54 %
47 %
51 %
43 %
40
20
0
Choosing the
right foods
Losing weight
Getting regular Managing stress
exercise