Transcript Communication between Older Patients and Their Physicians

Communication between Older
PTs and Their MDs
Ronald D. Adelman, MD
Michele G. Greene, DrPH
Risa Breckman, LCSW
Communication between Older
PTs and Their MDs
• Why is older PT-MD communication
important?
• What makes communication in the
geriatric medical encounter different?
• The role of the third (or more) person in
the medical encounter
• Practical communication skills for the
geriatrician
• Accessing the psychosocial history
Why is Older PT-MD Communication
Important?
PT OUTCOMES:
• Satisfaction
• Adherence to medication regimens and
other therapeutic recommendations
• Knowledge and recall
• Utilization of health services and
associated costs
• Health status
MD Outcomes
• Satisfaction
• Malpractice suits
• Ability to diagnose and treat
• A more difficult-to-capture and
intangible outcome of MD-PT
communication is the development
of a healing relationship based on
trust, empathy and masterful
medical care.
What makes communication in
the geriatric medical encounter
different?
• Attitudes toward older people
• Medical issues
• Psychological and social issues
Attitudes Toward Older People
• Ageism is the system of destructive false
beliefs about older people
• We live in an ageist society – what are the
implications?
Ageism
• Ageism is found among health care
professionals
• Stereotyping can lead to
misattributions and inadequate medical
intervention
• Ageism is the last acceptable “ism”
• Ageism is found among older people
themselves
What makes medical issues in the
geriatric visit different?
• Multiple chronic illnesses
• Atypical presentation of disease
• Polypharmacy
• Multiple MDs
• Importance of team
What makes medical issues in the
geriatric visit different?
• Sensory issues
- decreased hearing
- decreased vision
• Cognitive issues – more common in the oldold
- dementia-ism – stereotyping of all PTs
with dementia as the same
What makes psychosocial issues
in the geriatric visit different?
• Psychological and social issues
- e.g., more losses (bereavement,
function)
- fears about their own future,
dependency
- caregiving issues
- social isolation
• Goals of care, advance directives, meaning, end-oflife care
What makes communication in
the geriatric medical encounter
different?
• Presence of third (or more) person in
the medical visit
Setting the Stage
- PT = 91 years old
- Accompanied to the visit by her
daughter-in-law
- MD is an internist with no geriatric
training
- PT and MD have known each other for
5 years
Dyadic vs Triadic Visits
• Older PTs were frequently excluded from
conversations in which the third person was
present
• Older PTs were less assertive, expressive,
and had less joint decision-making and
shared laughter in triads than in dyads
• Older PTs raised fewer topics in triads than
in dyads
• Older PTs were less responsive to their own
topics in triads than in dyads
Effective Communication
Skills in Geriatric Medicine
• MDs and PTs are in agreement that there is
inadequate time available for the visit.
• Many geriatricians realize that the initial
intake may take 2 or 3 visits.
• Time spent learning the identity of the PT
early in the relationship will save time later
on.
Developing the Relationship
• Most PTs evaluate MDs based on their
interpersonal skills and not on their
medical knowledge and technical skills
• Introduce self
• Shake hands; sit down
• Obtain permission for third person to
be present
Developing the Relationship
• Ask PT’s preference for form of
address
• Utilize appropriate social amenities
(e.g., “how nice to meet you,” “thank
you”)
• Provide orientation to the visit
• Determine the patient’s agenda
• Pay attention to nonverbal cues
Effective Communication Skills
Identify sensory deficits that may impact communication:
Vision
- sit close to the PT
- make sure the room is well-lit
- utilize large print educational materials and forms
Hearing
- amplification devices
- clear view of mouth for lip-reading
- speak up, do not mumble, enunciate
Functional deficits
- help PT to examining table
- determine if PT needs help with undressing
- impact of environment
History-Taking
• Use open-ended questions
• Listen to responses and allow the PT to
speak for several minutes
• Avoid interruptions
• Establish an atmosphere in which
sensitive issues can be raised (e.g.
normalize difficult topics)
• Avoid litanies
Combating Ageism
• Obtain a life history to access
personhood of the patient
• Health promotion/disease prevention
• Offer state-of-the-art medical care
• Avoid misattributions
• Eliminate patronizing talk
• If there is an accompanying person,
talk to the patient
History-Taking of Psychosocial
Content
• MDs may not want to raise psychosocial
issues with older PTs as they do with
younger PTs
• In a recent study, depression was discussed
in only 7% of follow-up geriatric visits.
• Psychosocial screening tool
Providing Information
When PTs do not understand what is
wrong with them, they are less able to
take an active role in their care.
• Avoid technical language and jargon
• Determine PT’s level of health literacy
• Young-old consumerist perspective
• Provide most important information
first
Providing Information
• Do not overload
• Have PTs repeat back what they
have learned
• Provide take-home educational
materials
Effective Communication Skills
• Power of touch
• Joint decision-making
• Shared laughter
• Physician “memory”
• Use of phone
Effective Communication Skills
Assessing cognitive impairment
- PTs want MDs to initiate discussion of cognitive
issues
- Normalize discussion of cognition
- Importance of MD reassurance and support
- Importance of family member or significant other
Effective Communication Skills for
PTs with Cognitive Impairment
1. Be memory trigger for PTs
2. Give ample time for PT responses. Avoid
interruptions.
3. Focus on information exchange rather than PT’s
accurate use of words.
4. Speak clearly and slowly
5. Be the soother rather than provocateur
6. Use yes/no or close-ended questions