Transcript Teaching Cultural Competency New Docent Orientation Monday

Effective Communication Skills
with Families and Colleagues
CMH Fellows Curriculum
August 7, 2007
Timothy P. Hickman, MD, MEd, MPH
Associate Professor, Department of Pediatrics and Department of
Medical Education and Research
Cultural Competency Master
Office of Cultural Enhancement and Diversity
University of Missouri-Kansas City School of Medicine
Learning Objectives
• Describe research in parent-provider-child
communication in pediatrics
• Discuss communication styles and how they
might effect interdisciplinary and patient
communication
• Identify approaches to taking a history that will
elicit health beliefs and traditional medical
practices from any patient
• Discuss incorporating a cultural history into the
clinical history
ACGME Core Competencies Addressed
• Patient Care
• Interpersonal and Communication Skills
• Professionalism
Communication Quotient Activity
Cincinnati Children's Study
• Methodology
– Survey of Attending Physician, Nursing Staff,
and Parents
– Probably Case Series Design (Baseline for
RCT)
• Sample
– 44 PGY1 residents scheduled for pediatric
rotations (8 not eligible)
– Physician, Nurses, Parents: Convenience
sample
Brinkman, 2006
Cincinnati Children's Study
Parent and Physician Rating of Residents
100
Percent Yes
80
60
Physician
Parent
40
20
0
Showing Respectful Explained
Interest
Listened
Shared
Decisions
Brinkman, 2006
Significant Differences
• Physician > Parent Rating of Residents
– None
• Parent > Physician Rating of Residents
– Sharing Decisions (p<0.3)
Brinkman, 2006
Cincinnati Children's Study
Nursing Staff and Physician Rating of Residents
100
Percent Yes
80
60
Physician
Nurse
40
20
0
Respect
Staff
Accept
Suggest.
Respect
Confident.
Comm. with
Staff
Comm. With
Pt/Fam
Brinkman, 2006
Significant Differences
• Physician > Nurse Rating of Residents
–
–
–
–
–
–
Treat staff with respect
Accept Suggestions
Good team member
Sensitive and empathetic
Respect confidentiality
Honesty and integrety
• Nurse > Physician Rating of Residents
– Effectively plan course of care
– Anticipate post discharge needs
Brinkman, 2006
Discussion
• Percentages reflect how often the highest item
on a 5 point scale was selected
• Parents mean rating for all items was about 57%
• Physician and parents had similar ratings on
resident-parent interaction but physicians
frequently marked unable to observe
• Parent and nursing staff provide unique
perspectives
Brinkman, 2006
Birmingham Children’s Hospital
• Methodology
– Independent analysis of doctor-parentcommunication
– Surveys of parents and children
– Case Series
• Sample
– Convenience sample
– 51 outpatient visits, 12 doctors
Wasmer, 2004
Birmingham Children’s Hospital
Percent of Contribution to Visit by Time
5%
28%
Doctor
Patient
Child
67%
Wasmer, 2004
Birmingham Children’s Hospital
Percent of Contribution to Visit by Turn
10%
Doctor
Patient
Child
52%
38%
Wasmer, 2004
Discussion/Conclusions
• Growing evidence that children should
participate in clinical encounters including
shared decision making
• Most research indicates very low
communication by children
Wasmer, 2004
Active Listening Skills
• Attentive body language
– Posture and gestures showing involvement
and engagement
– Appropriate body movement
– Appropriate facial expressions
– Appropriate eye contact
– Non-distracting environment
Robertson, 2005
Active Listening Skills
• Following skills (Giving the speaker space
to tell their story in their own way)
– Interested ‘door openers’
– Minimal verbal encouragers
– Infrequent, timely and considered questions
– Attentive silences
Robertson, 2005
Active Listening Skills
• Reflecting skills (Restating the feeling
and/or content with understanding and
acceptance)
– Paraphrase (check periodically that you’ve
understood)
– Reflect back feelings and content
– Summarize the major issues
Robertson, 2005
Communication Styles
• Direct
– Meaning is conveyed through explicit statements
made directly to the people involved. No need to rely
on contextual factors such as situation and timing.
• Indirect
– Meaning is conveyed by suggestion, implication,
nonverbal behavior or other contextual cues. This
allows one to avoid confronting another person or
cause them to lose face.
Foreign Affairs Canada and International Trade Canada, 2007
Communication Styles
• Linear
– Discussion is conducted in a straight line,
almost like an outline. There is a low reliance
on context.
• Circular
– Discussion is conducted in a circular manner.
The main point is often left unstated. There is
a high reliance on context.
Foreign Affairs Canada and International Trade Canada, 2007
Communication Styles
• Attached
– Issues are discussed with feeling and
emotion.
• Detached
– Issues are discussed with calmness and
objectivity, conveying the speaker’s ability to
weigh all the factors impersonally.
Foreign Affairs Canada and International Trade Canada, 2007
Communication Styles
• Intellectual Engagement
– Any disagreement with ideas is stated directly, with
the assumption that only the idea, not the
relationship, is being attached. (We’re just having a
friendly discussion – don’t take it personally’.)
• Relational Confrontation
– Relational issues and problems are confronted
directly, while intellectual disagreement is handled
more subtly and indirectly.
Foreign Affairs Canada and International Trade Canada, 2007
Communication Styles
• Concrete (Factual)
– Issues are best understood through stories,
metaphors and examples, with an emphasis on the
specific, rather than the general.
• Abstract (Big Picture)
– Issues are best understood through theories,
principles and data, with emphasis on the general,
rather than the specific.
Foreign Affairs Canada and International Trade Canada, 2007
Communication Style Activity
Why Conduct a Culturally
Competent History
• Increasing diversity of U.S. population
• Importance of health belief
– Diagnosis
– Compliance
– Traditional Treatments
• Importance of history in diagnosis and
decisions about diagnostic and therapeutic
options
Culturally Competent Care
• Recognizes the complexity of cultural
influences
• Issue specific not culture specific
• Takes advantage of epidemiology but
creates a uniform approach to any person
• Learn about culture but avoid stereotyping
Parallels with “Discipline”
Specific History
• Pediatrics
– Developmental Stages
– Caregivers vs. Patient
– Wide belief in traditional health practices
•
•
•
•
Feeding
Discipline
Crying Infant
Disease Susceptibility
Culturally Competent History
• Greeting
– Respectful
– Addresses formally (Mr., Mrs.)
• Why they came to see the physician
• Health beliefs regarding the illness
– Kleinman’s questions
Culturally Competent History
• Avoid showing reaction or making
judgments about patient’s beliefs
– Avoid judgmental or condescending
statements
– Neutral facial expression
– Avoid making assumptions
– Avoid alienating or emotionally laden terms
Culturally Competent History
• Inquire about medical decision making
authority
• Use lay terms
• Show empathy
• Ask final question: “Is there anything else I
can help you with or any other questions
that you have?”
Questions
1. What do you thinks caused your
problem?
2. Why do you think it started when it did?
3. What do you think your sickness does to
you? How does it work?
4. How severe is you sickness? Will I have
a short or a long course?
Questions?
5. What kind of treatment do you think that you
should receive?
6. What are the most important results you hope
to receive from this treatment?
7. What are the chief problems your sickness has
caused you?
8. What do you fear most about your sickness?
Cultural History Activity
References
• Boyd SD. Using active listening: improve your
communication skill with the most powerful tool
available. Nurs Manage. 1998;29(7):55.
• Brinkman WB, Geraghty SR, Lanphear BP, Khourey
JC, et al. Evaluation of resident communication skills
and professionalism: a matter of perspective.
Pediatrics. 2006;118(4):1371-1379.
• Carrillo, J. E., Green, A. R. & Betancourt, J. R. Cross
cultural primary care: A patient based Approach. Ann
Intern Med. 1999;130: 829-834.
References
• Foreign Affairs Canada and International Trade
Canada. Virtual Campus: Independent Learning
Module on International Work Skills. Cross-Cultural
Skills. Available at: http://www.dfait-maeci.gc.ca/ypijpi/pdf/Cross-Cultural_Skills-en.pdf Accessed March
27, 2007
• Kleinman A, Eisenberg L, Good G. Culture, illness
and care: Clinical lessons from anthropologic and
cross-cultural research. Ann Intern Med. 1978;88:
251-258.
• Kreps G, Kunimoto E. Effective communication in
multicultural heath care settings. Thousand Oaks,
CA: Sage Publications; 1994.
References
• Robertson K . Active listening: more than just paying
attention. Australian Fam Phys. 2005;34(12):10531055.
• Spector R. Cultural Diversity in Health and Illness.
5th ed. Upper Saddle River, NJ: Appleton and Lange;
2000.
• Wasmer E, Minnaar G, Abdel Aal N, Atkinson AM et
al. How do peadiatricians communicate with children
and parents? Acta Paeditrica. 2004;93:1501-1506.
Questions