Transcript Communication Skills - Calgary Emergency Medicine

Communication Skills
October 23, 2003
Moritz Haager
Dr. S. Pandya
Objectives

Conflict resolution & negotiation
• What are the barriers to communication
in the ED?
• What strategies & models exist for
effectively dealing with conflict?
Dealing with consultants
 Giving bad news
 Telephone advice
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Why are we talking about this?
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“teaching physician-physician
communication skills in EM training
programs is in its infancy”
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O’Mara. Communication and conflict resolution in
emergency medicine. Emerg Med Clin NA 17. 1999
“Although the ‘Core Content for
Emergency Medicine’ includes the topic of
interpersonal skills, there remain no
published guidelines for teaching these
skills within an ED residency..”

Williams et al. Emergency department senior house
officers’ consultation difficulties: Implications for
training. Ann Emerg Med. 31. 1998
The Importance of Communication

“Communication skills are the most
important determinant of patient
satisfaction with care..”
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Brown et al. Effect of clinical communication
skills training on patient satisfaction. Ann
Intern Med. 131: 822-29. 1999
The Importance of Communication

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“…absent appropriate communication
skills, doctors cannot meet their
responsibilities as medical professionals”
“..I do not ever remember having a
faculty member sitting with me to talk
about my feelings about death and
suffering, or attempt to help me reach an
understanding about what my patients go
through.”
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Whitcomb. Communication and professionalism.
Patient education and Counseling 41: 137-44. 2000
Historical Perspective

In my father’s time, talking with the
patient was the biggest part of
medicine, for it was almost all there
was to do.”
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Lewis Thomas
The focus has shifted away from the
pt to focusing on disease with our
increased ability to accurately Dx &
Tx
Barriers to Communication

ED probably the worst place
• Divergent pt & physician expectations of
role of ED & goal of visit
• Lack of understanding of triage system
• Patient-doctor relationship arises out of
necessity rather than choice
• Loud & hectic environment
• Frequent interruptions & lack of privacy
• Balancing department flow & addressing
pt needs
Barriers to Communication
Telephone consultations
 Appearance & pt perceptions

• Youthful appearance
• Female gender
• Lack of formal dress
Social, cultural, language
 Pt impairment

• EtOH, drugs, disease states
Language & Culture
Huge issue in Canada
 Virtually all communications research
& models based on western
principles & values
 Unknown as to how these apply to
different cultures but easy to accept
that the same question put to
persons of different backgrounds can
have tremendously different meaning

Is there any proof this is a problem?

Taylor et al. Complaints from emergency
department patients largely result from
treatment and communication problems.
Emerg Med 14: 43-49. 2002
• Retrospective review of ED complaints
• Found that most likely to complaints were from
very old, very young, females, and non-english
speaking
• 33.4 % related to Dx and Tx
• 31.6% related to communication
• 11.9% related to delay in Tx
• 71.5 % resolved through communication
alone!!
Is there any proof this is a problem?

Williams et al. Emergency department senior
house officers’ consultation difficulties:
Implications for training. Ann Emerg Med. 31.
1998
• Conducted survey of SHO’s working in ED in England
regarding most difficult cases encountered & cause of
difficulty
• Found that communication problems were a factor in
76% of cases compared to lack of knowledge in 52%
• This did not change significantly over 4 months implying
no significant improvement with experiences
• Authors conclude that formal communication training
may be of benefit
Communication Problems
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Views conflicting with pts 40%
Pts w/ mental or behavioural problems 24%
Intoxicated or aggressive pts 12%
Distressed / anxious pts 7%
Difficult to obtain Hx 10%
Uncooperative / manipulative pt 5%
Language barrier 3%
Pt unable to speak or hear 3%
Children 2%
Conflict of opinion w/ other staff 2%

Williams et al. Emergency department senior house
officers’ consultation difficulties: Implications for training.
Ann Emerg Med. 31. 1998
Elements of Effective Communication
Listening
 Speaking
 Receiving feedback effectively


Marco and Smith. Conflict resolution in
Emergency Medicine. Ann Emerg Med. 40:
347-9. 2002
Model of Prinicipled Negotiation
Separate the people from the
problem
 Focus on interests rather than
positions
 Invent options for mutual gain
 Insist on objective criteria in judging
an agreement
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
Fisher & Ury. Getting to yes. 2nd ed. 1991.
Penguin Book, NYC, New York
The Challenge

It seems apparent that
communication skills are:
• Central to practicing medicine
• A common problem area in the ED
• A potential area for improving pt &
physician satisfaction
How do we teach communication?
 How do we evaluate whether the
curriculum works?

Does Specific Training Make a
Difference?

Langewitz et al. Improving communication skills – A randomized
controlled behaviorally oriented intervention study for residents in
internal medicine. Psychosom Med 60: 268-76. 1998.
• Randomized 42 residents to intervention (22.5 hrs of
communications training) & control groups
• Assessment of pt-oriented interview skills in videotaped
simulated clinical encounters using Revised Maastricht
History and Advice Checklist by blinded observers at 0 &
10 months
• Simulated pts also were surveyed for their satisfaction
with the clinical encounter using the American Board of
Internal Medicine Patient Satisfaction Questionnaire
• Found that both groups improved over time, but the
intervention group significantly more than the controls
• Actors were more likely to recommend physicians from
the intervention group to friends or family
Assessing Communication Skills

Rosenzweig et al. Assessing emergency
medicine resident communication skills
using videotaped patient encounters:
Gaps in inter-reliability. J Emerg Med 17:
355-61. 1999
• Videotaped 50 pt-resident encounters
• Analysis of only 11 using a checklist of 23
desirable & 9 undesirable behaviours by 3 EP’s
and 2 medical educators
• Only able to achieve moderate-excellent interobserver reliability on 10 of the 32 items
Key Communication Skills
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Introductions
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Rapport
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Introduce self by name
Ask or state pt’s name
Greet family or friends present
Social overture prior to data
gathering
•
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Gives comfort
Investigates or acknowledges
emotional response to illness or
ED experience
Gives reassurance
Talks Pt through physical exam
•
Clearly acknowledges Pt’s
viewpoint
Attempts to negotiate w/ Pt
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Allows Pt to tell story
Uses open-ended questions
Active listening indicators
Checks understanding by
summarizing information
Contracting / Informing
•
Conflict Management
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Information Gathering
Explains immediate plan for
further evaluation & Tx
Discusses expected time frame
Guides expectations of possible
outcomes
Checks Pt understanding of info
given
Non-Verbal Communication
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Position closer to head than feet
Emphatic & appropriate physical
touch
Appropriate eye contact
Posture oriented toward pt
Rosenzweig et al. Assessing emergency medicine resident
Communication skills using videotaped patient encounters: Gaps
In inter-reliability. J Emerg Med 17: 355-61. 1999
Communication Skills Improve w/ Training

Klamen & Williams. The effect of medical education on
students’ patients satisfaction ratings. Acad Med 72: 57-61.
1997
• Cohort study of 133 medical students
• Compared scores on standardized patient
interviews using the American Board of
Internal Medicine Patient Satisfaction
Questionnaire in 2nd yr with repeat exams in
4th yr
• Used medical residents doing same exams as
controls
• Found that mean scores improved over time
• Did not perform calculations to determine
statistical significance making it difficult to
draw any conclusions
Consultation Requests
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Go et al. Enhancing medical student
consultation request skills in an academic
emergency department. J Emerg Med 16:
659-62. 1998
• Simple comparison of taped telephone
consultation requests made by medical
students briefly trained with sheet outlining
structure of request with untrained EM
residents
• Medical students found to use significantly
more likely to use previously identified
important criteria of effective consultation
Consultation Requests
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Medical Student Telephone Consultation Sheet
• Hello Dr.______, this is _______ in the ED. I have a pt I
would like to present to you
• Pause for acknowledgement
• Mr_______ is a ___ yo _______ who comes in today
complaining of ______
• Gives relevant Hx and data
• I think the most likely diagnosis is _____
• This is what I have done for him already _____
• I’d like you to evaluate him for ________
• His condition right now is __________
• Thank you
• Total time should be less than one minute

Go et al. Enhancing medical student consultation request
skills in an academic emergency department. J Emerg
Med 16: 659-62. 1998
Do Communication Skills Seminars
Improve Pt Satisfaction?

Brown et al. Effect of clinician
communication skills training on patient
satisfaction. Ann Intern Med 131: 822-29.
1999
• Randomized physicians to taking a 10 hr
communication skills seminar at different time
points
• Assessed pt satisfaction using Art of Medicine
Survey scores before and after taking seminar
• Found that physicians self-assessment of
communication skills was improved, but no
statistically significant change in pt satisfaction
scores was noted
Criticisms
Simulated situations – difficult to
know how this impacts upon pt
satisfaction in real life
 Perhaps the amount of training was
not enough, or the time for the
training to manifest to short to be
detectable
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Conclusions
Difficult to get a sense from the
literature that specific courses aimed
at improving communication skills
produce tangible benefit
 However this may be as much a
function of the study designs as well
as the limitations of objectifying
something that is inherently
subjective in nature
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Bad News
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Definition
• “situations where there is either a
feeling of no hope, a threat to a
person’s mental or physical well being, a
risk of upsetting an established lifestyle,
or where a message is given which
conveys to an individual fewer choices
in his or her life”
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Dosanjh et al. Barriers to breaking bad news
among medical & surgical residents. Med Ed
35: 197-205. 2001
Advance Directives
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A study of audiotaped discussions about advance
directives found:
• Physicians tended to focus on more clear cut scenarios
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E.g. irreversible brain damage vs. severe infection
Pretty clear that most pts do not desire intervention when
there is no hope of recovery
• More common, uncertain scenarios were inadequately
explored
• Pts reasons & values underlying their responses were
also rarely elicited
• Concluded that such advance directive discussions are
inadequate to properly guide the physician and family in
times of crisis
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Tulsky et al. Opening the black box: How do physicians
communicate about advance directive. Ann Intern Med
129: 441-9. 1998
Death Notification
Unexpected ED deaths are not
uncommon (~0.3% of visits)
 Represent a major source of stress
for EP’s particularily if the deceased
was a child
 Little effort focused on teaching how
to inform relatives of death of a
loved one in medical school or
residency
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Death Notification

Buss et al. The preparedness of
students to discuss end-of-life issues
with patients. Acad Med 73: 418-22.
1998.
• Surveyed 226 4th yr medical students
about conveying end-of-life issues
• 41% felt they were adequately prepared
to do discuss this with their pts
• 27% had actually had such a discussion
with a pt
Death Notification in the ED
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Tends to be more difficult
• Death usually unexpected
• No prior relationship w/ pt or family
• Previously noted barriers to
communication in the ED
• Time demands
Death Notification Guidelines
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Make sure you are speaking to the right family
Take them to a quiet room
• Give them a sense that you are not rushing off to see the next
pt
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Sit down with them
Identify yourself & your role
Communicate with emotion
• Convey warmth, caring, & empathy
• Appropriate physical touch
• Allow them to dictate the pace
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Briefly summarize what happened before the pt arrived and
while in the ED
• Get a sense from them of how they saw the pt’s health
• Provide warning of what is to come
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Olsen et al. Death in the emergency department. Ann Emerg
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Ptacek & Eberhardt. Breaking bad news. JAMA. 276: 496-502.
1996
Med 31: 758-65. 1998
Death Notification Guidelines
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Avoid “medicalese” : Use simple clear language – tell them
the pt “died” rather than euphemisms
Reassure them everything possible was done
• This includes reassuring them that they did the right things
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Expect & allow for grief response
• Expect a range from pathologic grief to anger & resentment
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Let them see the body
• Body & resus room should be cleaned as much as possible
• Prepare family for what they will see
• If body terribly disfigured may want to discourage viewing
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Ask about tissue donation & autopsy
Encourage them to ask questions
Provide them with follow-up support
• Offer clergy or social worker support
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Olsen et al. Death in the emergency department. Ann Emerg Med
31: 758-65. 1998
Ptacek & Eberhardt. Breaking bad news. JAMA. 276: 496-502.
1996
Autopsy Request
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Why do them?
• Explanation of unexpected deaths
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Can help improve care in ~50% of cases by clarifying
Dx or guiding research
Can help grieving process (i.e. everything was done
that could be done)
Discovery of new diseases
Quality assurance
Vital statistics
Validation of diagnostic tests
Dx of genetic or infectious Dz and subsequent
Tx of affected contacts
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Olsen et al. Death in the emergency department.
Ann Emerg Med 31: 758-65. 1998
Organ Donation
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ED deaths will be limited to ischemiaresistant tissues:
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Liver, kidney (if ongoing CPR)
Cornea
Bone
Skin
Tendon & fascia
Cartilage
Veins
Heart valves
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Olsen et al. Death in the emergency department.
Ann Emerg Med 31: 758-65. 1998
Organ Donation
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Contra-indications to organ donation
• Infectious disease
• Cancer (can donate corneas)
• Toxic exposures (some exceptions)
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Olsen et al. Death in the emergency
department. Ann Emerg Med 31: 758-65.
1998
Organ Donation
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How to ask
• Wait until after family has viewed body
• Put in terms of letting pt have one final
act of goodwill

E.g. Do you think _____ would have wanted
to help someone else as his/her final act
here by becoming an organ donor?