Patient – Doctor Communications The Trust Equation Mark S. Litwin, MD, MPH Professor of Urology and Public Health October 2, 2010

Francis Peabody, MD JAMA 1927 Young graduates have been taught a great deal about mechanisms of disease, but very little about the practice of medicine. The significance of intimate personal relationship between physician and patient cannt be too strongly emphasized. Hospitals…are apt to deteriorate into dehumanized machines. The art and science of medicine are not antagonistic but supplementary to each other. The Care of the Patient

From Cancer Patient to Cancer Survivor: Lost in Transition Institute of Medicine 2006, Cancer Care Trajectory

Essential Elements of Survivorship Care 1. Prevention and detection of new cancers and recurrent cancer 2. Surveillance for cancer spread, recurrence, or second cancers 3. Intervention for consequences of cancer and its treatment (lymphedema, sexual dysfunction, pain, fatigue, psychological distress in survivors and caregivers, employment and insurance concerns, quality of life) 4. Coordination between specialists and primary care to ensure that health needs are met (health promotion, immunizations, health screenings, care of concurrent conditions). From Cancer Patient to Cancer Survivor: Lost in Transition Institute of Medicine 2006,

IOM Recommendations on Health Care Quality in America 1. Care based on continuous healing relationships 2. Customization based on patient needs and values 3. The patient as the source of control 4. Shared knowledge and the free flow of information 5. Evidence-based decision making 6. Safety as a system property 7. The need for transparency 8. Anticipation of needs 9. Continuous decrease in waste 10. Cooperation among clinicians Crossing the Quality Chasm Institute of Medicine 2001,

The Basic Rules Real Estate: Location, Location, Location Medical Care: Communication, Communication, Communication,

Patient-Doctor Communication Multiple studies have shown a positive influence of quality communication on health outcomes. Patient’s key concerns must be directly and specifically solicited and addressed. Clinician must gain an understanding of the patient's perspective on the illness. Teutsch, Med Clin N Amer 2003

Patient-Doctor Communication Patient concerns can be wide ranging: Fear of death, mutilation, disability Ominous attribution to pain symptoms Distrust of the medical profession Concern about loss of wholeness, role, status, independence Denial of reality of medical problems Grief Fear of leaving home Other uniquely personal issues Teutsch, Med Clin N Amer 2003

Patient-Doctor Communication Explore patient values, cultures, and preferences Avoid being judgmental or scolding Appropriate reassurance or pragmatic suggestions Therapeutic benefit just from venting concerns Teutsch, Med Clin N Amer 2003

Patient-Doctor Communication Know the psychology of behavioral change and establish a systematic framework for interventions Five As of patient counseling: 1. Assess 2. Advise 3. Agree 4. Assist 5. Arrange Teutsch, Med Clin N Amer 2003

Keys to Successful Communication Paternalism Consumerism Shared decision-making Teutsch, Med Clin N Amer 2003

Tips 1. Allow extra time for older patients 2. Avoid distractions 3. Sit face to face 4. Maintain eye contact 5. Listen 6. Give patients an opportunity to ask questions and express themselves Robinson et al, Fam Pract Manag 2006

Tips 7. Speak slowly and clearly 8. Use short, simple words and sentences 9. Stick to one topic at a time 10. Simplify and write down your instructions 11. Use charts, models and pictures 12. Frequently summarize the most important points Robinson et al, Fam Pract Manag 2006

Practice the Basic Skills Verbal: Paraphrasing Reflecting Summarizing Questioning Barnard, Non-verbal: Relaxed posture Eye contact Gestures Facial expression Voice Active listening

Francis Peabody, MD JAMA 1927 The good physician knows his [her] patients through and through. Time, symptahy, and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient. The Care of the Patient