Foundation Doctor Teaching 18/11/09 COMMUNICATION SKILLS Foundation Doctor Teaching 18/11/09

Objectives To understand the difference between a patient-centred and a doctor-centred approach To explore the advantages and disadvantages of both these approaches To identify specific strategies to elicit the patient’s agenda To apply this to breaking bad news

All talk But no trousers?

Or the holy grail for the ultimate Doctor?

Models and theories 1957 : M Balint - The Doctor, His Patient and The Illness 1964 : E Berne - Games People Play 1975 : Becker & Maiman - Sociobehavioural Determinants of Compliance 1975 : J Heron - Six Category Intervention Analysis 1976 : Byrne & Long - Doctors Talking to Patients 1977 : RCGP definition - Physical, psychological & social 1979 : Stott & Davis - The Exceptional Potential in Each Primary Care Consultation 1981 : C Helman - Disease vs Illness in Gen Practice 1984 : Pendleton et al - The Consultation 1987 : R Neighbour - The Inner Consultation 1987 : R C Fraser - Clinical Method: A Gen Pract Approach 1996 : Kurtz & Silverman The Calgary-Cambridge Observation Guide to The Consultation

Evidence? Papers regarding patient compliance with medication, qualitative studies re satisfaction etc. No references to RCTS found personally.

But complaints..... .....different story

Complaints Utah and Colorado study 15,000 claim reviews 3% filed negligence claims 77% of claims there was no negligence 55% of claims there was no adverse outcome Studdert et al, 1999

What motivates patients to claim? 80% of complaints related to poor communication. Health Service Report Victoria 1993 To correct deficient standards of care To find out what happened and why To enforce accountability Compensation for accrued/future costs Vincent et al LANCET 1994

Negative communication behaviour by Doctors increases likelihood of claim – even when there has been no adverse outcome. Lester and Smith 1993, West J Med

Greater than 50% of 263 patients (who complained) claimed that they were so turned off by the Doctor that they wanted to claim against the Doctor before the alleged event occurred. Mangels 1991, Med Econ

What do doctors not want? What do patients want? What do doctors want? What do doctors not want? What do patients want? What do patients not want?

We know what we want! What do patients say they want?

Frequent complaints Patient felt rushed Received no explanations Felt ignored or devalued Felt deserted Hickson et at 1994

No Complaints Asked patient opinions Patient perceived that sufficient time was spent Laughed Explained the process of the consultation Levinson and Roter 1997

Doctor centred: advantages Taking a history is doctor centred Medical thoroughness and good pattern recognition are a hallmark of this style Is often appropriate The doctor is in control Patients often want powerful doctors who have reassuring authority

Doctor centred: disadvantages Afraid of opening up a can of worms Taking too much time You only get the answers to the questions you ask Will you find out what the patient thinks Some patients don’t like this approach.

The patient’s story Tell me what’s going on?

The patients beliefs, hopes and fears A useful “aide-memoire” is: ICE Ideas - what the patient believes about the problem, for instance what might be causing it. Concerns - what worries the patient about it. Expectations - what the patient is hoping for, or thinks is the best way to tackle the problem.

WHAT ARE THE QUESTIONS THE DOCTOR CAN ASK?

What are you thinking???? Did you have any thoughts of what might be causing this? --- if so what were they? Do you have other concerns about the cause? What where you hoping I could do to help? What would be the most important things to address for you? What do you understand about ....? What would you feel about this treatment?

How’s this?

Observation Think about: the processes that are taking place (rapport, questioning, listening) the clinical information that is elicited – the content the non verbal communication Judge the extent to which the agenda, process and outcome are determined by the doctor or the patient

What are you thinking? ?