Transcript Document 7445721

Ana Maria Lopez, MD, MPH, FACP
Associate Professor of Clinical Medicine and Pathology
[email protected]
520-626-2271
1-Outline facilitator and barriers to
effective communication
 2-Discuss the implementation of
office practices to facilitate
communication
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Goals
Improve communication with patient
 Effectively deal with patient emotions
 Examine communication barriers
 Deliver bad news in a caring way
 Understand the medical appointment
and provider/patient communication
from the patients’ perspective
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Elements of effective patient-physician
communication
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Efficient information exchange
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Rapport
Empathy
Focus on patient-centered care
Verbal and non-verbal communication
Collaborative informed decision-making
(Frosch & Kaplan,199;Kaplan,
Greenfield, Gandek, Rogers, & Ware, 1996)
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Listening Skills: develop relationship
Knowledge: of the function/structure of the
medical interview and the emotional effects
of illness on the patient’s responses
Personal Growth: Understand how personal
biases, fears, and values influence
interaction
Attitude: Positive regard for patient and
her/his opinions help engage patient in
her/his own health care
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Skill Sets for
Effective
Provider/Patient
Communication:
Technical Skills
“People” Skills
Learning Skills
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Use open ended rather than forcedchoice/direct questions
Use summarization and transition
statements
Effectively gather information from patient
Use a kind and concerned voice tone
Smoothly redirect patients when tangential
or side talk is no longer productive
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Repeat questions only to clarify or verify
information
Define all medical terms used for easier
comprehension
Try not to interrupt and apologize for
interruptions
Detect and explore possible concerns
Encourage questions
Effectively close the appointment with a
summary
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Use appropriate body contact
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Shake hands
Use appropriate body language
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Relaxed, but professional posture
Face patient and make eye contact
Avoid verbal/non-verbal judgment
 Respect patients’ rights and privacy
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Respond appropriately to constructive
criticism
 Recognize your own limitations and
accept them
 Recognize your personal biases and
opinions and do not let them interfere
with a patient/provider relationship
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Reflection
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Recognize and name emotions as they
arise
Example: “Mrs. Smith, I see this problem is
disturbing to you.” or “Mr. Jones, I realize
that this must be frustrating for you.”
Legitimating
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Make explicit statements to validate the
patient’s emotional response
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Support
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Partnership
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Be willing to address all concerns
Express willingness to work together
Example: “Let’s talk about this problem
together and try to develop some
solutions.”
Respect
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Recognize the patient’s accomplishments
or coping efforts
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Prepare the patient by prefacing there is a
difficult topic to discuss
Inform the patient/family so that they are
able to comprehend the situation and make
sound decisions
Try not to have any interruptions and/or
distractions while breaking bad news
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Turn off cell phone, pager, etc.
Close door and don’t have medical staff
entering/leaving the room
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Deliver information in a timely manner
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Get the information out there without
being overly detailed
Assess the patient’s present
physiologic and emotional state
 Express sorrow for patient’s pain
 Be prepared for patients to react in
different ways
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Anger, disbelief, sadness, denial
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Language barriers
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Use an interpreter (if available) over a
family member to translate
Medical interpreters have more knowledge
of medical terms and will be able to
remove emotion from telling the patient
medical information
Try to have information distributed to
patients available in multiple languages
Which of the following is the strongest
predictors of an individual’s health status?
A) Age
B) Income
C) Literacy skills
D) Education level
E) Racial or ethnic group
C) Literacy skills
AMA-MSS Subcommittee on Health Literacy
Community Service Committee
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Illiteracy: total inability to read and write
Functional Illiteracy: ability to only
read/write/understand below 5th grade
level
Marginal Literacy: ability to only
read/write/understand between the 5th
and 8th grade level
Literacy: ability to read/write/understand
at the 8th grade level and above
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The ability to read, understand, and
use healthcare information to make
effective healthcare decisions and
follow instructions for treatment
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“… half of our adult population has
deficiencies in reading or
computational skills.”
(AMA Council on Scientific Affairs, JAMA 1999)
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Do your patients understand what you
are telling them?
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22% of adult Americans are functionally
illiterate; an additional 27.5% are marginally
literate
Therefore, nearly half of American adults
(90 million patients) do not have sufficient
literacy skills to fully function in society
All segments of the population are affected
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Percent of physicians who know about
Health Literacy:
33%
Percent of physicians who make changes
in patient communications after learning
about health literacy:
66%
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Number of years of education not
equal to amount learned
24% of Functionally Illiterate (NALS
Level 1) people are high school
graduates
Provides the most comprehensive
view of general literacy skills of
American adults (1992)
 5 Levels
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Level 1: Functionally Illiterate
◦ CANNOT:
 use bus schedule, find intersection on map
 read a simple story to a child
 fill out social security application
Level 2: Marginally Literate
◦ CANNOT:
 use bus schedule
 read a bar graph
 write a letter of complaint
Level 3 & 4: Functionally Literate
Level 5: High-Level Literacy
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Level
Level
Level
Level
Level
1:
2:
3:
4:
5:
22%
27.5%
31.5%
16%
3%
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Average annual
cost of all
Medicaid
enrollees:
$3,000
Average annual
cost of low
literacy
enrollees:
$13,000
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Low literacy patients have:
◦ more medication errors
◦ excess hospitalizations
◦ longer hospital stays
◦ more E.D. visits
◦ generally higher level of illness
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RESULT: An excess cost of $50-73
billion per year to the US healthcare
system
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Trouble understanding:
◦ when next appt is scheduled
◦ medical vocabulary (bowel, polyp, colon,
etc.)
◦ basic disease concepts
◦ how to use medical devices (asthma inhaler)
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Health Knowledge Deficits:
◦ Diabetic patients less likely to know symptoms of
hypoglycemia
◦ Patients with low literacy are less likely to
maintain tight control of their diabetes
Less healthy behaviors:
more smoking, including during pregnancy
◦ more exposure to violence
◦ less breastfeeding
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High Risk Groups
◦ Elderly
◦ People with limited education
◦ Ethnic Minorities (Latino, AA)
◦ Recent Immigrants to the US
◦ People born in the US but English is a
second language
◦ Low income
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Behaviors
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registration forms incomplete or inaccurate
frequently missed appointments
noncompliance with medication
lack of follow-through with tests or referrals
eyes wandering over a page
very slow to finish
sounding out words
looking confused
 Responses
◦ “I forgot my glasses”
◦ “Let me take this home so I can
discuss it with my children”
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Shame and Stigma
◦ 68% have never told their spouse
◦ 75% have never told their healthcare provider
◦ 19% have never told anyone
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may bring decoy reading materials
66-75% of adults in NALS Level 1 say they
read “well” or “very well”
33.6% of low literacy patients do not admit
to having reading trouble
Poor Health Outcomes
 Over-utilization of health services
 Limited effectiveness of treatment
 Higher patient dissatisfaction
 Higher provider frustration
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Do social history first in patient evaluation,
adding questions about literacy skills in a
sensitive manner
◦ “How happy are you with the way you read?”
◦ “What do you like to read?”
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Ask questions in a safe and supportive
environment and in a neutral,
nonjudgmental fashion
Brown-bag medication review
◦ “When was the last time you took one of these pills?”
◦ “When was the time before that?”
◦ Do they read the label or look at the pill?
Not stupid
 All social classes
 Amazingly able to function
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The majority of people with low literacy
skills are white, native-born Americans
A. Make your practice patient-friendly
B. Communicating in an easy-to-understand
language
C. Creating and using patient-friendly written
materials
A. Make your practice patientfriendly
◦ Attitude of helpfulness from
clinicians and staff
◦ Help with office check-in and
scheduling appointments
◦ Repeat important instructions
B. Communicating in an easy-tounderstand language
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6 Steps to improve communication with
patients
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slow down
use plain, non-medical language
limit the amount of information provided, and repeat it
show or draw pictures
use teach-back or show-me technique
create a shame-free environment
C. Creating and using patientfriendly written materials
1. Written consent forms/ patient education
handouts
• most forms written 10th grade to graduate
level
• average US adult reads at 8th grade level
Principles for creating patient-friendly
written materials
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5th or 6th grade level
clear statements of instruction
avoid unnecessary background info
avoid lengthy review of anatomy or physiology
short sentences
large text
3. Non-written patient education
materials
• Graphic Illustrations
- pictures
- models
• Audiotapes
• Videotapes
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Comprehension barriers
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Assess the intellectual level of the patient
and speak appropriately
Offer patient education materials
Try to empathize with the patient
 Try to think of the experience from
the patient’s point of view
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Prepared for the Wellness Community and is
advocated by the UCLA Cancer Center
“As your physician, I will make every
effort to…”
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Provide you with the care most likely to be
beneficial to you.
Inform and educate you about your
situation and the various treatment
alternatives.
Encourage you to ask questions about your
illness and treatment.
Patient satisfaction
 Physician satisfaction
 Better patient care
 If patient’s information requests are
fulfilled, patients tend to be more
satisfied and experience fewer
symptoms and health problems
(Kravitz et al.,2002)
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“As your physician, I will make every
effort to…”
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Be aware that all major decisions about the
course of your care shall be made by you.
I will accept the responsibility for making
the decisions you want me to.
Assist you to obtain other professional
opinions if you desire.
Relate to you as one competent adult to
another.
“As your physician, I will make every
effort to…”
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Spend a reasonable amount of time with
you for each visit and honor all
appointments.
Return phone calls as promptly as possible.
Make test results available promptly.
Provide you with any information you
request concerning my training, experience,
philosophy, etc.
“As your physician, I will make every
effort to…”
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Respect your desire to try treatments that
might not be conventionally accepted and
give you my honest opinion about such
treatments.
Maintain my active support and attention
throughout the course of the illness.
“I hope that you, as the patient, will
make every effort to…”
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Adhere to our agreed-upon treatment plan.
Be as candid as possible with me about
what you need and expect from me.
Inform me if you desire another
professional opinion.
Honor appointment times.
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Become a more
effective patient
Improve
communication
skills
Enhance
appointments
What is my main problem?
What do I need to do?
How do I take my medicine?
When do I need to be seen again?
Why is it important for me to do this?
 These questions can help patients take their medications
properly and take care of their health.
Patient “To Do List” Prior to an
Appointment
 Make a list of topics to discuss in the
visit
 Write down questions/concerns
 Take notes (bring a pen and paper)
 Arrange to have a support person
accompany them to the appointment
Patient “To Do List” Day of Appointment
 Arrive on time for the appointment
 Update clinical/insurance information
 Make sure all contact information is
current
Patient “To Do List” After Appointment
 Keep all paperwork from appointment
together and in an easily accessible
place
 Review notes and follow up with
doctor or nurse if questions arise
 Fill any prescriptions that were written
during the appointment and talk with
the pharmacist about them
Effective health care provider/patient
communication is important for both
parties
 Increases satisfaction for the doctor
and the patient
 Improves clinical better outcomes
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