Transcript Communication skills in medicine

Communication skills in medicine
Where art meets science
Dr Sanjay Suri
Consultant Paediatrician
Rotherham NHS Foundation Trust
Rotherham
2014
Doctors
Knowledge
Perceived power
Health
Responsibilities
Middle class
Patients
Beliefs
Vulnerable
Frightened
Unwell
Rights
Any class
What is communication?
Latin
Communicare = (to have something in) common
Oxford English Dictionary
“The exchange of information between individuals,
by means of speaking, writing or using a common
system of signs or behaviour”
Microsoft Encarta Dictionary 2001
The climate we live in…
 Complex illnesses and treatments
 Healthcare teams
 Increased patient expectations
 Blame and Complaint culture
 Litigation
 Diversity
 Resource limitation
Myths about communication skills
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Experience
Observing seniors
Personality trait
Knowing your subject
Command of English
Articulate
Responding to verbal cues
Being nice
Giving time
Consultation skills of young doctors
Patients preferred those who
 Introduced themselves
 Were sympathetic
 Appeared self-confident
 Listened to them
 Responded to verbal cues
 Asked precise and simple questions
 Did not repeat themselves
Maguire P et al 1989
Consultation skills of young doctors
Quote
 “Time is a great teacher but unfortunately it kills all its
pupils”
Hector Berlioz
French composer
1803-1869
Experience is……
…the ability to commit
the same mistakes with
increasing confidence
How long
(on an average) before a
doctor interrupts the
patient?
Primary care
Secondary care
22 seconds
92 seconds
Spontaneous talking time
Langewitz, W. et al. BMJ 2002;325:682-683
Copyright ©2002 BMJ Publishing Group Ltd.
What do patients want ?
Give me 5!
 Eye contact
“Nothing worse than not getting eye contact from the doctor”
 Partnership
“Patients want to be people that doctors do things with rather than do
things to”
 Communication
“Patients and doctors may have trouble understanding one another”
 Time
“If one wish could be granted, it is for more time with the doctor”
 Appointments
“Patients want to see their doctor within a reasonable time”
[Mike Stone Director Patients Association Harrow BMJ 2003;326:1294(14 June)]
Listen to the patient
They
are
telling
you
the
diagnosis !!
GMC
“Listening and good communication skills
were widely seen not only as a useful
means to improve the patient experience
but also assisting diagnosis and patient
concordance”
Setting standards : Views of members of the public and doctors on the standard of
care and practice they expect of doctors
Alison Chisholm
Liz Cairncross
Janet Askham
Picker Institute Europe 2006
Why bother?
Benefits to patients
 Patients problems are identified more accurately
 Adherence to treatment instructions is improved
 May improve health outcomes – better emotional
health, symptom resolution and pain control
 Likely to reduce the incidence of clinical error
Benefits to professionals
 May relieve pressure in an emotionally demanding
profession
 Job satisfaction may be enhanced
 Patients are less likely to complain
 Reduced likelihood of being sued
Evidence for benefits
 The longer the doctor waits before interrupting the
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patient, the more likely they are to discover the full
spread of issues ( Marvel 1999)
Picking up and responding to patient cues shortens
rather than lengthens the visits (Levinson 2000)
Asking patients to repeat in their own words increased
retention by 30% (Bertakis 1977)
Patients who are viewed as partners and informed of
treatment rationales are more adherent to treatment
( Schulman 1979)
Communication was the most important factor in
compliance (McLane 1995)
What stops us?
Barriers
Barriers
 Lack of skills
 Inadequate knowledge & training
 Undervaluing the importance of communicating
 Lack of time
 Uncomfortable topics (e.g. child protection)
 Lack of confidence
Barriers
 Tiredness/ Stress
 Language barriers (e.g. overseas doctors/patients)
 Personality and class differences between doctors
and patients
 Concerns regarding confidentiality
 Lack of knowledge of illness/condition
How to communicate better
Kalamazoo consensus statement
Essential components of a consultation
•Building the doctor–patient relationship
•Opening the discussion and gathering information
•Understanding the patient’s perspective
•Sharing information
•Reaching agreement on treatment
•Closure
Building the relationship
 Reduces anxiety and distress
 Improves willingness to engage
 Break the ice
 Offer choice to see them alone first
 When the child does not speak…..
 Rapport building
Opening the discussion
 Opening statement eg
What can I do for you?
What are your concerns about Sam?
 How to involve children…
Eye contact
Patience
Use name
Open posture
Gathering information
 Listening skills
show you are listening
nonverbal behaviour
clarifying
summarising
 ICE
Ideas
Concerns
Expectations
Rapport building
 Company + privacy
 Distraction
 Praise
 Explanation
 Reassurance
Sharing information
 “Frame” your explanation
Tell them what you are about to tell them
Find out what they know already
Build on ICE
Use appropriate language
Use visual aids
Sharing information
 Check understanding
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Eye contact
Asking questions
Forward posture
 Offer other sources of information
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Letters
Leaflets
Internet
Closing the consultation
 Summarising an action plan
 Safety netting
 Tell them what happens next
Sharing bad news
Preparation
 Are you the right person to give the news?
 Environment--ideally a quiet, comfortable, private room
 Minimize interruptions
 Do not appear rushed
 Know as much about the case as you can start.
 Consider who should be there. Consider an interpreter.
 Consider whether there may be cultural attitudes
 Introduce any members of the team or students
 Brace yourself for an emotional task!
Sharing the news
 Explore what is known by the patient/family already.
 Give information with honesty but sensitivity
 Try to use simple language
 Take care with prognostication
 Do not take all hope away--find some reason to be
optimistic.
 Allow time for questions.
 Listen to what the parents say.
 Don’t be worried by periods of silence.
Sharing the news
 Recognize and cope with family denial
 Do not impose the truth but if the patient asks, do not lie.
 Avoid false reassurances.
 Acknowledge that dealing with uncertainty is often harder
than knowing the diagnosis.
 Try not to let your own opinions interfere even if parents
push you to make a decision for them
 Give the parents sufficient information to be able to make
any decisions with you.
Sharing the news
 Recognize and acknowledge the feelings the parents or
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patient may have, such as anger.
Show empathy but do not lose control.
Try not to overload parents with too much information on
the first meeting.
Don’t stay too long. Closure can be difficult--make sure you
have arranged follow-up---then leave the room,
Leaving a nurse with the parents for a period of time
Most consultations last 15-30 mins – some may be longer
Follow up
 Arrange a review appointment relatively soon
 Provide written information if available (patient-information leaflets,
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support-group literature).
Suggest writing down any questions they think of
Document in the notes what information the parents have been given
and who was present.
At review appointments, update the news, for instance if further test
results are available.
There may be ongoing bad news to communicate..
Liaise with the primary healthcare team (GP, health visitor) and any
other relevant professionals.
Consider debriefing for the staff involved.
Bereavement counselling
Any questions?