Enhancing Clinician-Patient Communication for Every Day Practice: A Workshop on the Four Habits Model of Clinical Communication ___________________________________________________________________________.

Name: Enhancing Clinician-Patient Communication for Every Day Practice: A Workshop on the Four Habits Model of Clinical Communication ___________________________________________________________________________.
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Description: Enhancing Clinician-Patient Communication for Every Day Practice: A Workshop on the Four Habits Model of Clinical Communication ___________________________________________________________________________.

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 Glass, R. M. (1996). "The patient-physician relationship. JAMA focuses on the center of medicine [editorial; comment]." Jama 275:

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 ·financial ·organizational Trust Continuity ·longitudinal ·visit-based Interpersonal treatment Primary Care Clinical interaction ·communication ·physical exams Comprehensiveness ·knowledge of patient ·preventive counseling Integration Medical Care ; 36(5): 2

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 2

Relationship Between Trust and Disenrollment
1996 Trust (percentile) ___________________________________________________________________________ 95th 11.4% 75th 14.9% 50th 19.2% 25th 24.3% 37.1% 5th 10 20 30 40 50 % Voluntary Disenrollment Source: Safran et al. JFP 2001; 50: 4

Patient Trust as a Predictor of Adherence: Successful Behavior Change
Scale (percentile) ___________________________________________________________________________ 95th 32.9% 75th 31.7% 50th 29.9% 25th 28.0% 5th 24.3% 20 25 30 35 % Successful Change Source: Safran et al. JGIM 2000; 15 (supp):116. 10

Percent Report Cost-Related Non-Compliance
Cost-Related Non-Compliance by Quality of Physician-Patient Relationship ___________________________________________________________________________ 15% Percent Report Cost-Related Non-Compliance 8% 7% 6% MD-Patient Relationship Quality Source: Wilson et. al., SGIM 2001

Effect of a Patient Involvement Intervention on Diabetes Control
* Pre-Intervention Post-Intervention * p<0.001 Greenfield, S., et al. J Gen Intern Med, 1988; 3:

Effects of an Intervention on Health-related Quality of Life: Functional Limitations
Mobility (scored 0 3) Physical (scored 0 5) * * Greenfield, S., et al. J Gen Intern Med, 1988; 3: * p<0.01

Patient Preference for Active Involvement in Medical Decision-Making: Effect of a Patient Involvement Intervention * * p<0.001 Greenfield, S., et al. Annals of Internal Medicine, 1985; 102:

Effectiveness of patient information seeking
Effects of an Intervention on Patient Involvement in the Physician-Patient Interaction Number of controlling behaviors by patient (including questions, interruptions & directions) Effectiveness of patient information seeking * * Greenfield, S., et al. J Gen Intern Med, 1988; 3: * p<0.05

What Drives Patients’ Willingness To Recommend And How Are We Doing (2002)
Office Staff Percentile Rank Adjusted Clinical Team Relationship Duration Integration Interpersonal Treatment Health Promotion Patient Trust Knowledge of Patient Organizational Access Communication Visit-based Continuity Priority Improvements Correlation to Measure of Willingness to Recommend

Relationship Between Physician Communication and Medical Malpractice Risk
Source: Levinson et al. JAMA 1997; 277:

Primary Care Relationship Quality & Interactions, 1996-1999
___________________________________________________________________________ p < .001 Communication Interpersonal Treatment p < .001 Knowledge of Patient p < .01 Physical exams p < .001 Trust p < .01 Observed Change in Score Source: Murphy et al. JFP 2001.

Changing Rates of Preventive Care Processes, 1996-2001
HEDIS did not begin testing adolescent Hepatitis B immunization rates until 1997

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

___________________________________________________________________________ Skills Technique and Examples Elicit the patient’s concerns Start 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 Plan the visit with the patient Repeat 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 …”

___________________________________________________________________________ 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

Dr.: Hello Ms. Jones. What problems are you having?
Interrupted Opening Dr.: Hello Ms. Jones. What problems are you having? Pt.: I have chest pain. Dr.: When did it begin? [Interruption via closed ended question] Pt.: It started about three months ago. Dr.: Can you tell me more about it? Pt.: It’s a gnawing pain that hurts in the center of my chest. Dr.: Does the pain go into your arms or to your neck? Pt.: Yes. Dr.: Is it worse when you get excited? Dr.: Do you smoke cigarettes? Dr.: Are you currently taking any medication? Pt.: No. Beckman, H. B. and R. M. Frankel (1984). "The effect of physician behavior on the collection of data." Annals of Internal Medicine 101:

Dr.: Hello Mrs. Jones. What problems are you having?
Completed Opening Dr.: Hello Mrs. Jones. What problems are you having? Pt.: I’m having chest pain. Dr.: uh-huh. [Continuer] Pt. It’s a gnawing pain. Pt.: It starts in my chest and goes to my arm and jaw. Dr.: (silence) [Continuer] Pt.: It’s really frightening. Dr.: I see. [Acknowledgment] Pt.: You know, my father died from a heart attack and I’m afraid that the same thing may happen to me. Dr.: 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? Pt.: No. Beckman, H. B. and R. M. Frankel (1984). "The effect of physician behavior on the collection of data." Annals of Internal Medicine 101:

1. Facilitating the Opening of the Interview
Table 1. Relationship Between Interruption and Elapsed Time for 52 Interrupted Opening Statements. Concerns Expressed Encounters Mean Time to Before Interruption Interruption = … n < s Beckman and Frankel, Ann Int Med 1984 Beckman, H. B. and R. M. Frankel (1984). "The effect of physician behavior on the collection of data." Annals of Internal Medicine 101:

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 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 Elicit specific request Determine patient’s goal in seeking care: “How were you hoping I could help?” Explore the impact on the patient’s life Check context: “How has the illness affected your daily activities/work/family?”

___________________________________________________________________________ Payoffs Respects diversity Uncovers hidden concerns and diagnostic clues Reveals use of alternative treatments or requests for tests Improves diagnosis of depression and anxiety

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 the patient’s goals for the visit. What 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 happens when you do this well?
What 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 in a culturally appropriate manner to changes in body language and voice tone Make an empathic statement Look for opportunities to use brief empathic comments: “You seem really worried.” Compliment patient on efforts to address problem Convey empathy nonverbally Use 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 disease-related 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 hospital-based 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 diagnosis in terms of patient’s original concerns Provide education Explain 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

___________________________________________________________________________ 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.”

___________________________________________________________________________ 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.”

___________________________________________________________________________ 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
___________________________________________________________________________ Each study is represented by a unique shape and shade of marker. Some studies reported data for multiple time periods. This summary suggests that the relationship between AD adherence and time is approximately linear, with adherence dropping to 50 % by 6 months

Nonadherence Due to Cost (2003)
___________________________________________________________________________ 25% 26% 18% 28% Didn't fill Rx 1+ times 22% 16% 23% Skipped doses 19% 18% 12% Took smaller doses 35% 26% 37% Any cost-related nonadherence Total No Rx Coverage Low income Complex chronic Source: Safran et al. Health Affairs April 2005.

Rates of Cost- and Experience-Related Non-Adherence by Chronic Condition and Coverage Status
___________________________________________________________________________ Seniors with Coverage Seniors without Coverage Cost-Related Non-Adherence (%) Experience-Related Non-Adherence (%) Source: Safran et al. Health Affairs April 2005.

Rates of Nonadherence By Coverage Status, Poverty, and Disease Burden (2003)
___________________________________________________________________________ 35% 26% 37% Nonadherence due to cost 34% 28% 25% 27% Nonadherence due to experiences 19% 17% 15% 18% Nonadherence due to self-assessed need 52% 48% 40% Total: Any Nonadherence Total No Rx Coverage Low income Complex chronic Source: Safran et al. Health Affairs April 2005.

PATIENT TRUST AS A PREDICTOR OF ADHERENCE: ATTEMPTED BEHAVIOR CHANGE
Scale (percentile) ___________________________________________________________________________ 95th 87.8% 75th 85.5% 50th 81.9% 25th 78.4% 71.3% 5th 70 75 80 85 90 95 100 % Attempted Change Source: Safran et al. JGIM 2000; 15 (supp):116. 9

PATIENT TRUST AS A PREDICTOR OF ADHERENCE: SUCCESSFUL BEHAVIOR CHANGE
Scale (percentile) ___________________________________________________________________________ 95th 32.9% 75th 31.7% 50th 29.9% 25th 28.0% 5th 24.3% 20 25 30 35 % Successful Change Source: Safran et al. JGIM 2000; 15 (supp):116. 10

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? In the last 6 months, did your [fill in] give you as much information about managing your diabetes as you needed? % %

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? %

Enhancing Clinician-Patient Communication for Every Day Practice: A Workshop on the Four Habits Model of Clinical Communication ___________________________________________________________________________.

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Enhancing Clinician-Patient Communication for Every Day Practice: A Workshop on the Four Habits Model of Clinical Communication ___________________________________________________________________________.

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