Enhancing Clinician-Patient Communication for Every Day Practice: A Workshop on the Four Habits Model of Clinical Communication ___________________________________________________________________________.
Presentation on theme: "Enhancing Clinician-Patient Communication for Every Day Practice: A Workshop on the Four Habits Model of Clinical Communication ___________________________________________________________________________."— Presentation transcript:
1 Enhancing Clinician-Patient Communication for Every Day Practice: A Workshop on the Four Habits Model of Clinical Communication___________________________________________________________________________21-23 August 2006
3 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, 1996Glass, R. M. (1996). "The patient-physician relationship. JAMA focuses on the center of medicine [editorial; comment]." Jama 275:
5 THE INFORMED PATIENT By LAURA LANDRO Teaching Doctors How to InterviewPrograms Offer Strategies For Quickly Getting to Heart Of Patients' Problems, Fears September 21, 2005; Page D5The Wall Street Journal
8 FOUR HABITS APPROACH:HABIT 1:Invest in the Beginning
9 “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.”
10 FOUR HABITS APPROACH:HABIT 2ELICIT THE PATIENT’SPERSPECTIVE
16 We are what we repeatedly do. Excellence then, is not an act, but a habit.Aristotle
17 ___________________________________ Research Model___________________________________IndividualandOrganizationalCharacteristicsHealth CarePerformanceOutcomes
18 Essential Attributes of Primary Care Measured by the Primary Care Assessment Survey (PCAS) ___________________________________________________________________________Access·financial·organizationalTrustContinuity·longitudinal·visit-basedInterpersonaltreatmentPrimary CareClinicalinteraction·communication·physical examsComprehensiveness·knowledge ofpatient·preventivecounselingIntegrationMedical Care ; 36(5):2
19 Clinician-Patient Relationship Quality as a Driver of Outcomes Health OutcomesAdherenceSymptom ReliefClinical ImprovementBusiness OutcomesLoyalty to the practiceWillingness to recommendMalpractice risk
20 Relationship Quality Index from the Primary Care Assessment Survey (PCAS) InterpersonaltreatmentTrustRelationshipQualityCommunicationWhole-PersonOrientation2
21 Relationship Between Trust and Disenrollment 1996Trust(percentile)___________________________________________________________________________95th11.4%75th14.9%50th19.2%25th24.3%37.1%5th1020304050% Voluntary DisenrollmentSource: Safran et al. JFP 2001; 50:4
22 Patient Trust as a Predictor of Adherence: Successful Behavior Change Scale(percentile)___________________________________________________________________________95th32.9%75th31.7%50th29.9%25th28.0%5th24.3%20253035% Successful ChangeSource: Safran et al. JGIM 2000; 15 (supp):116.10
23 Percent Report Cost-Related Non-Compliance Cost-Related Non-Compliance by Quality of Physician-Patient Relationship___________________________________________________________________________15%Percent Report Cost-Related Non-Compliance8%7%6%MD-Patient Relationship QualitySource: Wilson et. al., SGIM 2001
24 Effect of a Patient Involvement Intervention on Diabetes Control *Pre-InterventionPost-Intervention* p<0.001Greenfield, S., et al. J Gen Intern Med, 1988; 3:
25 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
26 Patient Preference for Active Involvement in Medical Decision-Making: Effect of a Patient Involvement Intervention** p<0.001Greenfield, S., et al. Annals of Internal Medicine, 1985; 102:
27 Effectiveness of patient information seeking Effects of an Intervention on Patient Involvement in the Physician-Patient InteractionNumber 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
28 What Drives Patients’ Willingness To Recommend And How Are We Doing (2002) Office StaffPercentile Rank AdjustedClinical TeamRelationship DurationIntegrationInterpersonal TreatmentHealth PromotionPatient TrustKnowledge of PatientOrganizational AccessCommunicationVisit-based ContinuityPriority ImprovementsCorrelation to Measure of Willingness to Recommend
29 Relationship Between Physician Communication and Medical Malpractice Risk Source: Levinson et al. JAMA 1997; 277:
30 Primary Care Relationship Quality & Interactions, 1996-1999 ___________________________________________________________________________p < .001CommunicationInterpersonal Treatmentp < .001Knowledge of Patientp < .01Physicalexamsp < .001Trustp < .01Observed Change in ScoreSource: Murphy et al. JFP 2001.
31 Changing Rates of Preventive Care Processes, 1996-2001 HEDIS did not begin testing adolescent Hepatitis B immunization rates until 1997
32 FOUR HABITS APPROACH:HABIT 1:Invest in the Beginning
33 Habit 1: Invest in the Beginning ___________________________________________________________________________SkillsTechnique and ExamplesCreate rapport quicklyIntroduce self to everyone in the roomRefer to patient by last name and Mr. or Ms. until a relationship has been establishedAcknowledge waitMake a social comment or ask a non-medical question to put the patient at easeConvey knowledge of patient's history by commenting on prior visit or problemConsider patient’s cultural background and use appropriate XXXX, eye contact, and body language
34 Habit 1: Invest in the Beginning ___________________________________________________________________________SkillsTechnique and ExamplesElicit the patient’s concernsStart 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 interpreterPlan the visit with the patientRepeat concerns back to check understandingLet 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 …”
35 Habit 1: Invest in the Beginning ___________________________________________________________________________PayoffsEstablishes a welcoming atmosphereAllows faster access to real reason for visitIncreases diagnostic accuracyRequires less workMinimizes “Oh by the way … “ at the end of visitFacilitates negotiating an agendaDecreases potential for conflict
37 Dr.: Hello Ms. Jones. What problems are you having? Interrupted OpeningDr.: 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:
38 Dr.: Hello Mrs. Jones. What problems are you having? Completed OpeningDr.: 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:
39 1. Facilitating the Opening of the Interview Table 1. Relationship Between Interruption and Elapsed Time for 52Interrupted Opening Statements.Concerns Expressed Encounters Mean Time toBefore Interruption Interruption= … n < sBeckman and Frankel, Ann Int Med 1984Beckman, H. B. and R. M. Frankel (1984). "The effect of physician behavior on the collection of data." Annals of Internal Medicine 101:
40 FOUR HABITS APPROACH:HABIT 2ELICIT THE PATIENT’SPERSPECTIVE
41 Habit 2: Elicit the Patient’s Perspective ___________________________________________________________________________SkillsTechnique and ExamplesAsk for the patient’s ideasAssess 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 communityElicit specific requestDetermine patient’s goal in seeking care: “How were you hoping I could help?”Explore the impact on the patient’s lifeCheck context: “How has the illness affected your daily activities/work/family?”
42 Habit 2: Elicit the Patient’s Perspective ___________________________________________________________________________PayoffsRespects diversityUncovers hidden concerns and diagnostic cluesReveals use of alternative treatments or requests for testsImproves diagnosis of depression and anxiety
43 Habit 2: Elicit the Patient’s Perspective Condition: qaug dab pegEnglish translation:The Spirit Catches You and You Fall downMedical translation: Epilepsy
44 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.”
45 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.
46 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.
47 Habit 2 forms the basis of physician-patient collaboration Ask for the patient’s ideasWhat 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?
48 Questions: What happens when you do this well? What happens when this habit is overlooked or done poorly?
49 FOUR HABITS APPROACH:HABIT 3DEMONSTRATE EMPATHY
50 Habit 3: Demonstrate Empathy ___________________________________________________________________________SkillsTechnique and ExamplesBe open to the patient’s emotionsRespond in a culturally appropriate manner to changes in body language and voice toneMake an empathic statementLook for opportunities to use brief empathic comments: “You seem really worried.”Compliment patient on efforts to address problemConvey empathy nonverballyUse a pause, touch, or facial expression
51 Habit 3: Demonstrate Empathy ___________________________________________________________________________PayoffsAdds depth and meaning to the visitBuilds trust, leading to better diagnostic information, adherence, and outcomesMakes limit-setting or saying “no” easier
52 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.
53 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?
54 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 1958Blumgart: “neutral empathy;” Detachment is necessary to accurately observe and predict patients’ emotional states. NEJM 1964
55 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 ofMedical Practice, 1963
56 The Appeal of Detachment Detachment was mistakenly equated with:Objective diagnosesEffectivenessLess burn-out
57 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
58 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.
59 Empathy Makes A Difference: The Evidence Empathy & emotional engagement are equated with:More thorough diagnosesSuchman, Markakis, Beckman, Frankel, JAMA, 1997 (USA)AdherenceKim, Kaplowitz, Johnston Eval Health Prof 2004 (Korea)Satisfaction & trustShields, Epstein, Franks etal (2005)
60 Zachariae et al (2003)454 cancer patients & 31 physicians at an oncology outpatient clinic, Aarhus University Hospital, DenmarkMeasured many aspects of dr-patient relationshipEmpathy, as perceived by the patient, predicts satisfaction even after controlling for disease severity, sociodemographic factors, self-efficacy and prior distressGreater empathy associated with decreased post-visit distress post-visit (after controls)Empathy associated with greater disease-related self-efficacy
61 Breaking Bad News It is all too common in the life of a physician Physicians typically have little if any training in itIt often makes physicians, even experienced ones, uncomfortableIt is done poorly more often than not
62 Styles of Delivery (Friederichsen, Strang, & Carlsen, 2000) 30 patients admitted to a hospital-based home care unit (Uppsala, Sweden)The inexperienced messengerThe emotionally burdened expertThe rough and ready expertThe distanced doctorThe benevolent but tactless expertThe empathic professional
63 Delivering Bad News Empathically: Some Guidelines Find out what the patient knows alreadyFind out what the patient wants to knowShare the information simply and honestlyGive patient time to absorb the newsAcknowledge the patient’s emotionsName, legitimize, and support any emotionsOffer appropriate reassurance, but not false hopeMake plans for follow-up, short and long-termAssess support of family, friends, spiritual beliefs--involve loved ones
66 Habit 4: Invest in the End ___________________________________________________________________________SkillsTechnique and ExamplesDeliver diagnostic informationFrame diagnosis in terms of patient’s original concernsProvide educationExplain rationale for tests and treatmentsReview possible side effects and expected course of recoveryDiscuss options that are consistent with patient’s lifestyle, cultural values and beliefsProvide resources (e.g., written materials) in patient’s preferred language when possible
67 Habit 4: Invest in the End ___________________________________________________________________________SkillsTechnique and ExamplesInvolve the patient in making decisionsDiscuss treatment goals: express respect towards alternative healing practicesAssess patient’s ability and motivation to carry out planExplore 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 instructionsSet 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.”
68 Habit 4: Invest in the End ___________________________________________________________________________SkillsTechnique and ExamplesComplete the visitSummarize visit and review next stepsAsk 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.”
69 Habit 4: Invest in the End ___________________________________________________________________________PayoffsIncreases potential for collaborationInfluences health outcomesImproves adherenceReduces return calls and visitsEncourages self care
71 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
72 Nonadherence Due to Cost (2003) ___________________________________________________________________________25%26%18%28%Didn't fill Rx 1+times22%16%23%Skipped doses19%18%12%Took smallerdoses35%26%37%Any cost-relatednonadherenceTotalNo Rx CoverageLow incomeComplex chronicSource: Safran et al. Health Affairs April 2005.
73 Rates of Cost- and Experience-Related Non-Adherence by Chronic Condition and Coverage Status ___________________________________________________________________________Seniors with CoverageSeniors without CoverageCost-Related Non-Adherence (%)Experience-Related Non-Adherence (%)Source: Safran et al. Health Affairs April 2005.
74 Rates of Nonadherence By Coverage Status, Poverty, and Disease Burden (2003) ___________________________________________________________________________35%26%37%Nonadherence dueto cost34%28%25%27%Nonadherence dueto experiences19%17%15%18%Nonadherence dueto self-assessedneed52%48%40%Total: AnyNonadherenceTotalNo Rx CoverageLow incomeComplex chronicSource: Safran et al. Health Affairs April 2005.
75 PATIENT TRUST AS A PREDICTOR OF ADHERENCE: ATTEMPTED BEHAVIOR CHANGE Scale(percentile)___________________________________________________________________________95th87.8%75th85.5%50th81.9%25th78.4%71.3%5th707580859095100% Attempted ChangeSource: Safran et al. JGIM 2000; 15 (supp):116.9
76 PATIENT TRUST AS A PREDICTOR OF ADHERENCE: SUCCESSFUL BEHAVIOR CHANGE Scale(percentile)___________________________________________________________________________95th32.9%75th31.7%50th29.9%25th28.0%5th24.3%20253035% Successful ChangeSource: Safran et al. JGIM 2000; 15 (supp):116.10
77 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?%%
78 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?%