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Effective communication MBBS 1 Friday 13th May 2005 Professor Graham Martin.

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Presentation on theme: "Effective communication MBBS 1 Friday 13th May 2005 Professor Graham Martin."— Presentation transcript:

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2 Effective communication MBBS 1 Friday 13th May 2005 Professor Graham Martin

3 “The greatest problem in communication is the illusion it has been accomplished” George Bernard Shaw

4 What we need to cover Evidence about Communication Evidence about Communication The spoken word The spoken word Emotional voice tone Emotional voice tone Body language Body language Receiving the message Receiving the message Delivering Bad News Delivering Bad News Neurolinguistic programming (NLP) Neurolinguistic programming (NLP)

5 Other People’s Tragedy

6 Common descriptors of inappropriate medical student behaviours & attitudes arrogant arrogant power-seeking power-seeking inflexible inflexible defensive defensive dishonest dishonest patronising patronising brash brash egocentric egocentric isolated isolated insensitive insensitive self-centred self-centred uncaring uncaring indifferent indifferent selfish selfish antisocial antisocial amoral amoral devious devious prejudiced prejudiced flippant flippant rude rude aggressive aggressive condescending condescending rigid attitudes rigid attitudes judgemental judgemental

7 Medical Consumerism Doctor to Patient: Do you fully appreciate the risks of this procedure? Doctor to Patient: Do you fully appreciate the risks of this procedure? Patient to Doctor: Sure, you screw up and I’ll sue! Patient to Doctor: Sure, you screw up and I’ll sue!

8 9 February 2001 MEDICAL OBSERVER “Patients’ complaints cause years of hurt, study shows”

9 17 May 2002 MEDICAL OBSERVER “GPs left undefended as UMP walks away”

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11 Friday 8 December 2000 AMAQ MEDIA RELEASE Alternative models to the adversarial system should be identified. Alternative models to the adversarial system should be identified. Aim to speed up resolution and reduce high costs of litigation. Aim to speed up resolution and reduce high costs of litigation.

12 The nature of complaints UK Study 70 % of patient complaints Deserting the patient Deserting the patient Devaluing the patients views Devaluing the patients views Delivering information poorly Delivering information poorly Failing to understand the patients perspective Failing to understand the patients perspective

13 Types of Issues  Misdiagnosis  Treatment  Negligence  Medication  Conduct  Lack of Care  Cost  Assault  Access to Records  Confidentiality  Discrimination  Delays  Refused Treatment  Public Health  Overservicing  Hygiene

14 Complaint Issues 2000/01 (2,520) Treatment1,366 54% Treatment1,366 54% Communication405 17% Communication405 17% Access % Access % Rights286 11% Rights286 11% Administration130 5% Administration130 5% Costs 70 3% Costs 70 3%

15 Communication 2000/01 (405) Arrogance91 Arrogance91 Discourtesy68 Discourtesy68 Failure to Consult76 Failure to Consult76 Lack of Care/Consideration68 Lack of Care/Consideration68 Misinformation55 Misinformation55 Undignified Service8 Undignified Service8 Other39 Other39

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17 Who Can Make a Complaint? User of a health service. User of a health service. Someone chosen by the user if it would be difficult for them to complain themselves. Someone chosen by the user if it would be difficult for them to complain themselves. Legal Friend on behalf of an assisted citizen. Legal Friend on behalf of an assisted citizen. Minister for Health. Minister for Health. A person the Commissioner accepts in the public interest. eg another health provider A person the Commissioner accepts in the public interest. eg another health provider

18 The Health Rights Commission …. provides an independent, impartial and collaborative health complaints system designed to improve health care services and promote health rights and responsibilities in Queensland.

19 Reasons People Complain RegulationI want to ensure this event never happens to anyone else. RegulationI want to ensure this event never happens to anyone else. Information I want to find out what really happened. Information I want to find out what really happened. AccountabilityI want the person brought to account or disciplined. AccountabilityI want the person brought to account or disciplined. Compensation I want the money. Compensation I want the money.

20 Complaint Algorithm Poor communication + Patient’s unmet / unrealistic expectation + Adverse event or bad outcome = a writ or complaint

21 POOR RESPONSE

22 “After much consideration and as an act of my good faith, I have decided to allow copies of your medical record to be sent to you. You should be aware that I have no legal obligation to do this.” “After much consideration and as an act of my good faith, I have decided to allow copies of your medical record to be sent to you. You should be aware that I have no legal obligation to do this.”

23 Referral to Registration Boards 2000/01 (74) Medical 45 Medical 45 Pharmacy5 Pharmacy5 Psychologists2 Psychologists2 Dental16 Dental16 Chiropractors Chiropractors & Osteopath6

24 Registration Board Action Taken 2000/01 Deregistration10 Deregistration10 Suspension10 Suspension10 Conditions of practice4 Conditions of practice4 Censure/Reprimand4 Censure/Reprimand4 Fine1 Fine1 No further action22 No further action22

25 HELPFUL RESPONSE HELPFUL RESPONSE “The review of your complaint has provided useful suggestions in terms of process and staff training issues. As such, future patients will benefit from the critical examination of the way in we manage patient concerns” “The review of your complaint has provided useful suggestions in terms of process and staff training issues. As such, future patients will benefit from the critical examination of the way in we manage patient concerns”

26 Complaint Resolution Processes Local Resolution Local Resolution Assessment Assessment Conciliation Conciliation Investigation Investigation Referral to Registration Board Referral to Registration Board Referral to another entity Eg: Police Referral to another entity Eg: Police

27 Personal Injuries Proceedings Act 2002 “Expressions of Regret” “Expressions of Regret” Allows an individual to express regret about an incident without being concerned that the expression will be used as an admission of liability or negligence. This statement cannot then be used in court.

28 CONCILIATION A Collaborative approach to resolving health service complaints

29 Conciliation Outcomes  Change in practice or protocol.  Quality assurance changes.  Additional reparative treatment.  Apology.  Full explanation of what went wrong.  Independent assessment of treatment.  Financial settlements - 21%  July March 2001 : $1,500,000

30 Compelling evidence base Good communication leads to better health outcomes Good communication leads to better health outcomes Good communication is professionally rewarding. Good communication is professionally rewarding. Omission of adequate information about diagnosis, prognosis, treatment options leads to patient anxiety and dissatisfaction. Omission of adequate information about diagnosis, prognosis, treatment options leads to patient anxiety and dissatisfaction. Communication failures as opposed to technical negligence are significant complaints. Communication failures as opposed to technical negligence are significant complaints.

31 Sensitive Issues Child victims - custody issues Child victims - custody issues Minors seeking contraception, abortion or drug counseling Minors seeking contraception, abortion or drug counseling Elderly patients Elderly patients Patients with gynaecological problems Patients with gynaecological problems Sexually transmitted diseases Sexually transmitted diseases HIV patients. Victims of sexual assault. HIV patients. Victims of sexual assault. Mental Health Patients Mental Health Patients

32 Patients’ difficulties Understanding, especially in context of anxiety. Understanding, especially in context of anxiety. Low to moderate anxiety can focus attention. Low to moderate anxiety can focus attention. Significant anxiety or depression leads to an interpretation bias, anxiety about threat, depression about negative events Significant anxiety or depression leads to an interpretation bias, anxiety about threat, depression about negative events Intelligence has a weak but consistent relationship with recall Intelligence has a weak but consistent relationship with recall Recall of information is low (General medical outpatients = 54%, oncology = 25%) Recall of information is low (General medical outpatients = 54%, oncology = 25%)

33 Consultation structure and content and memory Patients usually recall the start and very end of the consultation best (primacy and recency effects). Patients usually recall the start and very end of the consultation best (primacy and recency effects). Topics of most relevance and importance to the patient are recalled well (eg medical information). Topics of most relevance and importance to the patient are recalled well (eg medical information). More statements made by the clinician the less the % of information recalled by patient. More statements made by the clinician the less the % of information recalled by patient.

34 Clinician cognitive bias Clinician estimates of the amount of information provided exceed that recalled by up to 900%. Clinician estimates of the amount of information provided exceed that recalled by up to 900%. The order in which patients present problems does not reflect clinical importance The order in which patients present problems does not reflect clinical importance In primary health care 54% of patients complaints and 45% of concerns not elicited. “What concerns you about this problem?” is rarely asked. In primary health care 54% of patients complaints and 45% of concerns not elicited. “What concerns you about this problem?” is rarely asked. Patients tend to seek information re prognosis, diagnosis, causation. Clinicians tend to provide information re treatment and drug therapy. Patients tend to seek information re prognosis, diagnosis, causation. Clinicians tend to provide information re treatment and drug therapy.

35 Patient Satisfaction Empathy, non verbal behaviour, perception of amount of information provided. Empathy, non verbal behaviour, perception of amount of information provided. Asking patients about their expectations of the consultation increases adherence even if expectations are not met Asking patients about their expectations of the consultation increases adherence even if expectations are not met Recall is enhanced by categorisation, signposting importance, summarising, repetition Recall is enhanced by categorisation, signposting importance, summarising, repetition Asking patients to repeat information in their own words increases recall by 30% Asking patients to repeat information in their own words increases recall by 30%

36 Clinician behaviour Unless you invite the patient to ask directly, they rarely ask important questions (assume Dr would tell them if important, seems “foolish”, guilt re taking up time). Unless you invite the patient to ask directly, they rarely ask important questions (assume Dr would tell them if important, seems “foolish”, guilt re taking up time). Usually little attempt to find out what the patient wants Usually little attempt to find out what the patient wants Detachment, inhibits patient self disclosure, warmth and empathy facilitate it. Detachment, inhibits patient self disclosure, warmth and empathy facilitate it. Non-verbal signs (the way that information is delivered) are significant. Non-verbal signs (the way that information is delivered) are significant.

37 In High Concern Situations, People Want to Know That You Care Before They Care What You Know (Vincent Covello) Listening/Caring/Empathy 50% - Assessed in first 9-30 seconds Listening/Caring/Empathy 50% - Assessed in first 9-30 seconds

38 So What do we do? Be clear, open and as direct as we can Be clear, open and as direct as we can Keep It Simple, Stupid! Keep It Simple, Stupid! Repeat Repeat Draw a diagram Draw a diagram Provide a handout to take home Provide a handout to take home Provide an Internet Site address if available, and patient has internet access Provide an Internet Site address if available, and patient has internet access Summarise Summarise Provide and opportunity for follow-up Provide and opportunity for follow-up

39 Rules for Communication Demonstrate respect for patients - whoever and whatever they are Demonstrate respect for patients - whoever and whatever they are Your attitudes will be perceived! Your attitudes will be perceived! Do not be in a hurry Do not be in a hurry Be available and accessible in a timely manner - particularly in the case of an adverse event or complication. Be available and accessible in a timely manner - particularly in the case of an adverse event or complication.

40 Rules for Communication Listen actively to a patient’s concerns Listen actively to a patient’s concerns Always acknowledge a criticism of treatment or care - and explore in a reasonable manner. Always acknowledge a criticism of treatment or care - and explore in a reasonable manner. Do not become defensive and short with a patient. Do not become defensive and short with a patient. Work even harder the more difficult the patient is Work even harder the more difficult the patient is

41 Rules for Communication Be open and honest about adverse events and complications. Be open and honest about adverse events and complications. Eg: medication errors Eg: medication errors

42 Rules for Communication Never criticise another health practitioner’s care. Never criticise another health practitioner’s care. “I would not have done that”. “I would not have done that”. “If you had only seen me sooner”. “If you had only seen me sooner”. Disputes in front of patients. Disputes in front of patients.

43 “By the way, Doc…..”

44 Case Examples Breast Cancer First Episode Psychosis

45 Voice Only 7% communication results from words used Only 7% communication results from words used 38% verbal behaviour 38% verbal behaviour tone of voice, timbre, tempo, volume tone of voice, timbre, tempo, volume 55% non-verbal 55% non-verbal posture, breathing, skin colour, movements posture, breathing, skin colour, movements Birdwhistle, 1970 Joseph Stalin Leon Trotsky Joseph Stalin Leon Trotsky

46 Body language Monitor your own body language Monitor your own body language Be aware that you can change deliberately if needed Be aware that you can change deliberately if needed Be careful not to overdo the changes Be careful not to overdo the changes Practice Practice

47 Exercise Neurolinguistic Programming


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