Transcript Communication as a discipline

Communication as a discipline
Claudia W. Allen, PhD
POM-1, August 17, 2009
Avoiding the
“Blah Blah Blah, Ginger” Effect
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Objectives
• You’ll know why good doctor-patient
communication is important.
• You’ll know what creates good communication.
• You’ll be aware of your “at risk” status as a med
student and future doctor.
• You’ll know what some physicians have done to
protect their abilities to be good communicators.
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How might good doctor-patient
communication further your goals?
– Better medical outcomes – you as a healer (helping
others)
– Fewer malpractice suits – you as an earner
(practical life)
– Greater physician satisfaction – you as a happy
person (personal development)
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Good doctor-patient
communication improves medical
outcomes:
• quicker resolution of chronic headaches
• reduced blood sugar values in diabetics
• improved blood pressure readings in hypertensive
patients
• reduced pain in cancer patients
• better functional capacity in heart disease and asthma
patients.
• lower stress hormones in radiology patients
• more realistic assumptions in patients making decisions
whether or not to engage in life extending therapies
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Fewer malpractice suits
Fewer ERRORS
due to better
information
Fewer CLAIMS
regardless of
quality of care
8 Avery JK. Lawyers tell what turns some patients
litigious. Med
Malpractice Rev 1985;2:35–7.
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Your sense of satisfaction with
medicine
When a group of physicians was asked what
enhances their work satisfaction the most, the
most frequently named factor was
“relationships with patients.”
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It starts in med school…
High empathy
Higher ratings of
clinical competence
in medical school.
Better history-taking
and physical exams
by fourth-year med
students.
Empathy in medical students. M Hojat et al. MEDICAL EDUCATION 2002;36:522–527; Collier JA, Willis MS, Robbs RS.
Assessment of empathy in a standardized-patient examination. Teaching Learning Med.1998;10:8–11.
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Good doctor-patient communication
What does it look like?
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Communication 101
Effective communication
more information
greater impact
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We call it communication,
but it’s really about relationship
The mechanics of good
communication are valuable as
tools to help you create a trusting
doctor-patient relationship.
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Relationships depend on empathy:
• the ability to put
oneself in another’s
shoes.
• "Identification with,
understanding of, and
vicarious experience
of another person's
situation, feelings,
The bridge between
and motives.”
us and “the other.”
The American Heritage Stedman's
Medical Dictionary
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People don’t care how
much you know,
until they know how
much you care.
Lewis Barnett, MD
UVA Family Medicine
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At least half of all
patient encounters
with a doctor,
whether primary
care or specialist,
REQUIRE behavior
change on the part
of the patient for
successful
treatment.
Caring  Buy-in
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Patient: Mr. Jones
Problem: increased hypertension
Question: Change medication or dosage?
Decision: Increase dosage
Real Problem: Mr. Jones not taking meds.
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Listening for emotion
Communicating skillfully with a
patient requires tuning to the
patient's emotions.
Halpern, J. What is Clinical Empathy? J Gen Intern Med. 2003 August;
18(8): 670–674.
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Skill 1
“Listening with both ears”
One ear:
medical
information
Other ear:
emotion in
patient’s
words, tone,
expression,
posture
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Skill 2
Reflect and listen, Repeat
3. Feedback
1. Hypothesize
2. Test
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Physicians very often miss
important clues about emotion.
Patient:
No, sir, I’ve never had a heart attack … I worked very hard when I
was a young man, a young boy. I was doing a man’s labor and I
was always told I had a good strong heart and lungs. But the lungs
couldn’t withstand all that cigarettes . . .
Physician: Yeah.
Patient:
Asbestos and pollution and second-hand smoke and all these other
things, I guess.
Physician: Do you have glaucoma?
Morse et al. Missed Opportunities for Interval Empathy in Lung Cancer Communication. Archives of Internal 20
Medicine, 2008; 168 (17): 1853
Sometimes we fear that all that
emotion will be overwhelming…
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But…ignoring emotion is inefficient
“When opportunities for empathy are
missed by physicians, patients tend to
offer them again, sometimes repeatedly.
This phenomenon can lead to longer,
more frustrating interviews, return visits,
and "doctor shopping" by patients who feel
dismissed or alienated.”
Hardee, J. T. A Focus on Patient-Centered Care and Office Practice Management:
The Permanente Journal: Fall 2003/Vol. 7, No. 4.
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So why is this difficult?
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In medicine as in life,
our strength is our weakness
• The symptom-focused nature of medicine:
the “terminal” in Room 6.
• The intense cognitive demands of medicine:
little mental space for empathy.
• The outcome-oriented focus of medicine:
lack of overt reward for empathy skills.
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Our human limitations
• Our own fatigue, hunger, pain.
• Our anxiety – can make it hard to slow down and
listen.
• Our fear of being overwhelmed. “What if I cry,
too?”
• Sense of failure when we see pain we can’t fix.
• Painful awareness of our own vulnerability to
illness and mortality. “
Arch Int med
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Extra demands in medicine “today”
Technology
Time
Regulation
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These barriers turn out to be very powerful.
Empathy scores start
out fairly high in
med school
students.
But they drop after
first year and then
again after third
year.
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"The public tells us they want
physicians who are good
diagnosticians and also caring
people. We start with students who
are very caring but have no
diagnostic skills and end up with
physicians with great diagnostic
skills but who don't care.”
(Yikes!)
Richard Frankel, MD, Prof of Medicine and Geriatrics at IU School
of Medicine
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“What would you prefer - a
doctor who holds your hand
while you die
or one who ignores you while you
get better?”
Greg House, TV-MD
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It’s great TV drama, but a false
choice in real medicine.
• In real life, good communication
is not separable from quality
medicine.
• It’s not a tradeoff.
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What’s the take home?
1. Learn to listen with both ears – keep one
ear out for emotion.
2. Reflect back what you’re hearing to your
patients: find out if you’re right!
3. Express your empathy – let them know
you care.
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People don’t care how
much you know,
until they know how
much you care.
Lewis Barnett, MD
Former Chair UVA Family Med
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So what can you do?
• Three strategies predicted higher levels of
well being and empathy in residents:
– I try to take a positive outlook on things.
– I nurture the religious/spiritual aspects of
myself.
– I incorporate a life philosophy stressing
balance in my personal and professional life.
J Gen Intern Med 2005 July; 20(7): 559-564.
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The Nuggets
• 1. A good doctor-patient relationship is key to
good health outcomes (it helps you do good!)
• 2. Good relationships with patients are the main
source of satisfaction for satisfied physicians
(they make you happy!)
• 3. A good doctor-patient relationship
reduces errors and the likelihood of being sued
whether or not there is an error. (Hence you
earn a living!)
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Good Doctor-Patient
Communication
1. Is this something I should care
about (invest energy in)?
2. If so, what are its key elements?
3. Have experienced physicians and
researchers identified any potential
problems that might get in my way?
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This is med school, right?
Why do we care about
“communication”?
The most dazzling medical expertise can go
right down the drain when it’s not
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communicated in an effective manner in the
Good communication is like
oxygen.
• When there’s plenty of it in the air, we
don’t even notice it. But when it’s
lacking, all other systems fail – we can’t
function.
• Without good doctor-patient
communication, our medical tools are
weakened or become useless.
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• It turns out that the effective
transmission of information depends on
a strong d-p relationship.
• It turns out that the most important
component of the strong relationship is
empathy.
• So empathy is the most powerful
component of effective communication.
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Communication Skill Sets
•
content skills – what you say
•
process skills – how you say it
•
Self-perception skills – awareness of
your own feelings and biases
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Metacommunication
• communicating about communicating
– “Do you follow me?”
– “You seem worried; is that right?”
– “I’m not sure I get what you’re saying.”
– “You sound really mad at me!”
– “Is it ok if I ask you some questions about
that?”
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Metacommunication - your life ring
• When content and
process don’t match up
• When a patient is very
upset with you or
something about his or
her medical care
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Why invite complaints?
As the patient, a metacomment inviting
feedback tells you:
– that the doctor is really listening;
– that the doctor cares enough to take the time to
pursue your concerns;
– that the doctor is not afraid of potentially unpleasant
emotion and so you can be honest, and
– that the doctor really cares how you feel.
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“Listening” includes attending to
non-verbal communication
Nonverbal attunement led physicians to pause
at moments of heightened anxiety, at which
times patients disclosed information. If
physicians did not do this, patients did not share
vulnerable information, despite the physicians
asking the patients appropriate and accurate
questions.
Suchman A, Markakis K, Beckman H, Frankel R. A model of empathic
communication in the medical interview. JAMA. 1997;277:678–82.
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The power of your positive attention
A physician simply
making contact by
observing to the baby’s
mother: “I can see she
has your eyes,” or
“He’s snuggled right
into you, isn’t he?”
engaged the mothers
more than other far
more complicated
interventions.
Brazelton et al.
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