Transcript basic doctoring EM

BASIC DOCTOR SKILLS
EM Conference 5/15/08
Joshua Rocker, MD
Pediatric Emergency Medicine
Schneider Children’s Hospital

Much of this talk is extracted from
articles I read and a lecture I heard
from Robert Strauss, MD
(EM attending in Poughkeepsie, NY)
What makes a good ER doc?
Are you a good ER doc?
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?
How can I become a better ER
doc?
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?
How do we measure our
abilities?
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?
What the ACGME expects of
you- Core Curriculum!
Patient Care
 Medical Knowledge
 Practice-based Learning and
Improvement
 Interpersonal and Communication Skills
 Professionalism
 Systems-Based Practice
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Are your thoughts and the
ACGME’s consistent?
Why not?
Because…
Competitive med school/residency
atmosphere (skills, knowledge based)
 Teaching communication/
compassion/professionalism is not easy
 It requires the educator to be a good
communicator and that is not simple
 It requires confronting residents regarding
personal issues
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Another measure of our
performance
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Press-Ganey Scores
5 Press-Ganey Scores (MD)
Did the doctor spend enough time with
you?
 Did the doctor keep you informed in a
language you understand?
 Did the MD seem attentive to your
questions and worries?
 Was the MD friendly and caring?
 Did you trust your MD?
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Press-Ganey Scores…
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Did they ask about skills or knowledge?
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What are your mother’s or grandmother’s
comments about their doctors?
What we notoriously do
Interrupt patients early in the encounter
 Fail to identify and prioritize patient’s
concerns
 Miss opportunities to understand and
acknowledge patient’s ideas and feelings
 Fail to understand importance of culture
and ethnicity
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More things we do wrong
Minimize patient’s role in their own care
 Underestimate pts health literacy
 Don’t negotiate differences well
 Don’t give bad news concisely and
compassionately
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Communication Skills
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When was the last time someone
commented on your communication
skills?
Towards colleagues?
 Towards patients?
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Communication Skills
Was that feedback helpful?
 Was it constructive?
 Did it change your behaviors?
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OKAY, IS THIS HOUR GOING
TO BORE ME?
OKAY, IS THIS HOUR GOING
TO BORE ME?

Why waste my time with this med school
bullshit!
Localio, NEJM, 7/91
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For every 7.6 negligent adverse event
there is only 1 lawsuit
Levinson, JAMA, 2/97
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Comparing MDs with no lawsuits and
MDs with lawsuits
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Those with no cases
•
•
•
•
•
•
Educated pt re: expectations
Sense of Humor
Solicited pt opinion
Checked pt understanding
Encourage pt to talk
Spent more time on routine visits
Hickson, JAMA, 10/94
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Comparing Ob/Gyns with little to no
lawsuits vs those with many
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Quality of care, same
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Perception of care, different
Basic facts about proper
communication skills
Greater patient and clinician satisfaction
 Greater patient understanding and
acceptance of treatment plan
 Reduce patient distress
 FEWER LAWSUITS
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Marvel, JAMA, ‘99
25% of FM MDs in their offices did not
solicit pts concern, ask why pt was there,
or how they can help
 28%- did all
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Time difference between their interactions:
Marvel, JAMA, ‘99
25% of FM MDs in their offices did not
solicit pts concern, ask why pt was there,
or how they can help
 28%- did all
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Time difference between their interactions:
6 Seconds
I am what I am…
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“Meaning well and trying hard do not
guarantee a good outcome.”
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“It takes 18 months to 2 years to change a
behavior… and you’ve really got to want
to.”
Harles Cone
I can’t change!
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Interventions directed to improve clinicianpatient communication demonstrated
Better patient self-management of DM
 Reduction of post-op morbidity
 Better coping and quality of life with cancer
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SKILLS
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1. Identify and remove barriers to
communication
Physical
 Psych/Social
 Cultural
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SKILLS
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2. Survey patient’s concerns
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Ask
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Don’t just listen to the facts/details, sense
their emotions
SKILLS
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3. Care
Listen with eyes and body
 Remain silent
 Be empathic
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SKILLS
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4. Negotiate a consensual agenda
Work with patient
 Make sure they understand and agree with
plan, otherwise… non-compliance
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(whose fault is that!)
Josh, wake up… that will take
forever
Josh, wake up… that will take
forever
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Evidence shows that these skills and the
skills of making explicit empathic and
caring statements in the end saves time
Albert Mehrebian on
Persuasion (%)
Verbal content
 Vocal Expression
 Visual Cues
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Albert Mehrebian on
Persuasion (%)
Verbal content
 Vocal Expression
 Visual Cues
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7%
38%
55%
Mehrebian on Persuasion
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We tend to overemphasize the content,
to convince them with words. If they
are not getting it, perhaps… you’re not
delivering it
Gorlin, NEJM, ‘83
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MDs frequently react to difficult situations
with avoidance
Become hostile/angry
 Feel Loss of control
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Gorlin, NEJM, ‘83
 Recommendations-
• Acknowledge your response
• Accept response is justified, but ill advised
(Raul May- “What makes us humans is the time
between impulse and action.”)
Clip of interaction….