Transcript Patient_Communication_2_of_3x

Improving Patient
Communication
Part 2 of 3: Verbal Communication
Patrick Hunt, MD, MBA
Educational Objectives
• Identify verbal communication strategies that
enhance patient understanding and satisfaction.
• Describe research findings about the
relationship of communication and malpractice
claims.
• Identify and demonstrate verbal communication
techniques which can lessen malpractice risk as
well as improve clinical outcomes and increase
patient satisfaction.
• Integrate improved verbal communication skills
into daily practice.
Pre-Questionnaire
•
The major determinant by which patients
base their decision to choose a physician
is:
A.
B.
C.
D.
Where they went to medical school
Number of years in practice
A compassionate and caring attitude
Amount of experience treating patients with
their medical condition
E. Whether or not they’re board certified
Pre-Questionnaire
•
Primary care doctors who have never
been sued:
A.
B.
C.
D.
E.
Solicited patients’ opinions
Encouraged patients to talk
Laughed and used humor more
All of the above
None of the above
Verbal Communication
• We’ll approach the verbal section by
correlating it to the behavior of doctors
who have never been sued.
A Comparison
• Primary care doctors who had never been sued
versus those who were:
– Used more orienting statements (educating patients
about what to expect and the flow of the visit).
– Solicited patients’ opinions.
• Ask the patient what they think.
–
–
–
–
Encouraged patients to talk.
Took time to explain and checked understanding.
Laughed and used humor more.
Spent enough time so patient didn’t feel rushed.
Orienting Statements
• Help patients get a sense of what the visit
is supposed to accomplish and when they
ought to ask questions.
– “First I’ll examine you, and then we’ll talk
about the problem.”
– “I will leave time for your questions at the
end.”
Empowerment
• Most patients make a self-diagnosis.
• It’s extremely helpful to elicit and
acknowledge it early in the interview.
During the Exam
• “Do you have any idea what may be
causing your symptoms?”
• “Thanks for sharing that with me. Let’s
see what we’ve got here.”
Share Your Diagnosis
• Discuss any discrepancies between your
conclusion and the patient’s.
Agree on a Treatment Plan
• If more tests are needed, tell what they are
and why the patient needs them.
• Discuss options.
• Tell them when they can expect results
and how they’ll get them.
Buy In
• Did I miss anything?
• Does that sound okay to you?
“Communication”
from the Latin communicare, “to
share or make common”
Two-Way Flow of Information
• “Taking a history” suggests an act of
extraction.
• Often it’s an assault of closed-ended
questions, punctuated briefly by faint “yes”
or “no” answers from the patient.
“BUILD A HISTORY”
rather than
“TAKE ONE”
Effective Dialogue
• Use open-ended questions that can’t be
answered with just a “yes” or a “no.”
• These invite patients to reflect on their
problems, pain and symptoms.
• Best open-ended question is: “And?”
Closed-Ended Questions
• Don’t use too early in the interview –
patient can feel shut out and passive, less
likely to volunteer.
• Announce they’re coming: “Now Mr.
Smith, I’d like to focus in on that chest pain
and ask you a series of questions…”
• a.k.a. “Smile and Nod” questions.
• Example: “Any….(symptom)”
Closed vs. Open
• Closed
– Is the pain in one spot
or all over?
– Is it mostly on the right
side?
– Did you try aspirin for
the pain?
• Open
– How would you
describe the pain?
– Where do you feel it
the most?
– What medication have
you tried?
Two best words to improve
doctor patient communication?
Two best words to improve
doctor patient communication?
“WHAT ELSE?”
Don’t Interrupt
• A JAMA article found that 72% of the
doctors interrupted the patient’s opening
statement after an average of ____
seconds.
Don’t Interrupt
• A JAMA article found that 72% of the
doctors interrupted the patient’s opening
statement after an average of 23 seconds.
Don’t Interrupt
• Physicians often redirect patients’ initial
descriptions of their concerns.
• Once directed, the descriptions are rarely
completed.
• Consequences of incomplete initial
descriptions include late-arising concerns
and missed opportunities to gather
potentially important patient data.
Don’t Interrupt
• “I don’t have time to listen to a patient
drone on and on…”
• Patients who are allowed to state their
concerns without interruption used only an
average of 6 more seconds.
Narrate During the Exam
• Explaining what you are checking for
builds trust and reassures the patient.
Restating
• Restate the patient’s basic ideas using
your own words.
• Shows that you are listening and
understanding.
Summarizing
• Summarize the major points made and
feelings the patient has expressed.
• “Let me see if I have this right…”
Assessment
• Tell them your opinions, your Dx if you
have one, then the plan.
Jargon Use
• Can cause resentment, making patients
feel befuddled, stupid, or angry.
• Doctors think they don’t use jargon, yet
studies show they do and often don’t
realize it.
Jargon Use
• Lay, easy-to-understand terms first.
• Bridge with “or as we call it…”
• Medical term last: “You have high blood
pressure, or as we call it…hypertension.
Hyper-tension.”
Verify Understanding
• Doctors checked for patient understanding
only ___ of the time.
Verify Understanding
• Doctors checked for patient understanding
only 34% of the time.
Verify Understanding
• Rather than putting the patient on the spot
by saying, “now repeat it back to me.”
• Put the onus on you: “We’ve covered a lot
of information here. Just so I can be sure
my explanation was clear, let’s go over
how you’ll be taking your medication…”
Verify Understanding
•
•
•
•
•
Write it down
Visuals
Assume 4th grade reading level
Tell a family member
Repeat, Repeat, Repeat
Up at the End
• Try to end the exam on a positive note
whenever possible without giving into
false-hope.
– “Let’s see how you do on this new blood
pressure medicine. I think you’ll have a lot
more energy to play with those grandkids.”
Don’t Forget
• Always THANK the patient for coming in
for the visit.
Enhance
• Note personal patient information
• Make small talk
• Take advantage of empathic moments
Patient Personal Information
• Jot down personal info nuggets in chart –
“Loves Lakers,” “Son accepted to West
Point” – that you’ll use next time the
patient comes in for a visit.
• Also share these with staff – and have
them ask the patient.
• Impact on patient is: “Wow. They all know
me here. They really care about me.”
Small Talk
• You’re double booked and running late
usually means small talk is DOA.
• If possible, do a few moments at the
beginning and end of interview.
• Try for 30 to 60 seconds.
Empathy
• Empathy means expressing your
understanding of the patient’s feelings,
values, and experience as if they were
your own.
• Look for empathic moments to further your
relationship with the patient.
Biggest Mistake –
Missed Moments
• Patient: “My stomach has really been
bothering me. I’ve been under a lot of
stress lately.”
• Doctor: “Are you still taking your ulcer
medicine?”
Biggest Mistake –
Missed Moments
• Patient: “My stomach has really been
bothering me. I’ve been under a lot of
stress lately.”
• Doctor: “I’m sorry to hear that. Tell me
more about the stress.”
Message
• You are interested in them, not just the
disease.
Queries
• “Can you tell me more about that?”
• “What has this been like for you?”
• “How has all of this made you feel?”
Clarifications
• “Let me see if I’ve gotten this right…”
• “Tell me more about…”
• “I want to make sure I understand what
you’ve said…”
Responses
• “Sounds like you are…”
• “I imagine that must be…”
• “I can understand that must make you
feel…”
Share Some of Your
Personal Details
• “Doctors that shared details of their social
and family issues had a greatly increased
number of satisfied patients.”
– Dr. Bernard Lown, Harvard School of Public
Health
Humor
• Humor and laughter are shown to have
positive psychological and biological
effects as well as acting as a
communication tool and social lubricant.
Using Humor in the
Patient-Physician Encounter
• Gentle humor can be an effective tool in
showing patients empathy, demonstrating
your humanness, and helping patients
relax in a stressful situation.
• Humor should be self-depreciating, should
never be mean-spirited, and must always
be beliefs sensitive to cultural and
personal preferences.
Using Humor Can Be A
Tricky Business
• In some ways one of the more difficult
techniques to use.
• Can do harm with used incorrectly.
• How have you used humor?
Time
• For YOU…time is real and rationed,
counted in precious seconds and minutes.
• For PATIENTS…time is a perception,
measured in warm smiles and murmurs of
understanding.
Cameos
• Primary care physicians who NEVER had
a claim against them also had longer visits
(18.3 vs. 15 minutes).
Time Perception
• When doctors sat down during an office
visit rather than stood, 96% of patients
thought the visit was longer even though
the time of both visits was exactly the
same.
Vocal Communication
Three dimensions to your voice
1. Volume
2. Rate/Pausing
3. Pitch
Vocal Communication
• Three dimensions
– Slow down and soften tone when asking
difficult questions.
– Combine with forward lean for greater effect.
– Pauses show control. They also allow the
patient a mental breather when assimilating
information.
Vocal Communication
• Vocal tone
– Even more critical for patients who may not
understand English very well.
• Volume
– Remember that older patients may not hear that well
– and may be too embarrassed to tell you they don’t
hear anything you’re saying.
• Pitch
– Monotone suggests boredom or lack of interest.
Vocal Communication
• “Ums” and “Uhs”
– What do they mean to you?
– “I’m thinking, I don’t know and I’m buying
time, I’m lying…”
Vocal Communication
• The effect of tone of voice on propensity to being
sued
– Audio recordings of doctors who had been sued and
others who hadn’t were made while they were talking
to patients.
– Both groups had the content filtered so that individual
words couldn’t be recognized.
– Findings showed that dominant voices and less
concerned tones tended to be in the sued group.
Vocal Communication
• Vocal Tone
– A compassionate, caring tone of voice,
increased patient satisfaction and compliance.
– There was no difference in the amount or
quality of information they gave their patients.
A Comparison
• Primary care doctors who had never been sued
versus those who were:
– Used more orienting statements (educating patients
about what to expect and the flow of the visit).
– Solicited patients’ opinions.
• Ask the patient what they think.
–
–
–
–
Encouraged patients to talk.
Took time to explain and checked understanding.
Laughed and used humor more.
Spent enough time so patient didn’t feel rushed.
• Doing these demonstrates to the patient that you
are compassionate, caring and concerned.
Decrease Risk of Being Sued
• Used more orienting statements
• Solicited patients’ opinions in caring tone of
voice
• Encouraged patients to talk
• Took time to explain and checked understanding
• Laughed and used humor
• Spend enough time so patient didn’t feel rushed.
Top Determinants of
Patient Satisfaction
•
•
•
•
•
Doctor understands the patient
Doctor’s tone of voice
Doctor asks about patient concerns
Patient feels comfortable asking questions
Patient perception that sufficient time is
being spent with them
Decrease Risk vs.
Patient Satisfaction
• Decrease Risk of Being
Sued
– Used more orienting
statements
– Solicited patients’ opinions in
caring tone of voice
– Encouraged patients to talk
– Took time to explain and
checked understanding
– Laughed and used humor
– Spend enough time so patient
didn’t feel rushed.
• Top Determinants of
Patient Satisfaction
– Doctor understands the
patient
– Doctor’s tone of voice
– Doctor asks about patient
concerns
– Patient feels comfortable
asking questions
– Patient perception that
sufficient time is being
spent with them
With these Techniques to Enhance
Communication You’ll Have…
• Higher patient satisfaction
– Patients assume equal level of confidence in doctors.
– Differentiating factor in building market share is
patient satisfaction.
• More business
– 84% of patients choose a particular physician based
on how well they communicate and whether or not the
clinician shows a caring attitude.
• Less risk of being sued
Rapid and Profound Effect on
Patient Satisfaction
• The techniques presented in this course
will significantly improve patient
satisfaction scores…
• …in many cases as high as 50%.
Benefits
• In addition to…
– Higher patient satisfaction
– More business
– Less risk of being sued
• You’ll also get…
– Better compliance rates
– More effective and shorter interviews
– Better health outcomes
In one way, the most
important benefit of all…
greater personal enjoyment and
satisfaction from your practice.
Applying these Techniques
• Change starts with awareness.
• Ask a colleague to come in during an
exam and provide feedback.
• Practice a few of these in a safe
environment with family or friends.
• With practice, techniques become part of
your natural style.
Post-Questionnaire
1. True or False
– Primary care doctors check for patient
understanding less than half of the time.
2. Doctors interrupt a patient’s opening
statement after an average of ___
seconds.
Post-Questionnaire
3. Physicians using a dominant tone of
voice while taking a history from a
patient:
A.
B.
C.
D.
E.
Have better rates of patient compliance
Have increased patient satisfaction
Have a greater likelihood of being sued
Have shorter examination times
Have better patient understanding of the
information given to them
Post-Questionnaire
4. Which of the following is not an empathic
statement?
A.
B.
C.
D.
E.
“How has all of this made you feel?”
“Are you still taking your ulcer medicine?”
“Let me see if I’ve gotten this right?”
“Tell me more about that.”
None of the above.
References
•
Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM. Physician-patient communication. The
relationship with malpractice claims among primary care physicians and surgeons. JAMA 1997
Feb 19;277(7):553-9.
•
Marvel KM et al. Soliciting the patient’s agenda: Have we improved? JAMA 1999; 281:283-287.
•
Korsch, B.M., Gozzi, E.K., Francis, V. Gaps in Doctor-Patient Communication. Pediatrics. 1968;
42(5):855-871
•
Ley, P., Bradshaw, P.W., Eaves, D. A Method for Increasing Patient’s Recall of Information
Presented by Doctors. Psychological Medicine. 1973; 3:217-219.
•
Coulehan JL, Platt FW, Enger B, et al. Let me see if I have this right ...: words that help build
empathy. Annals of Internal Medicine. August 2001; 135(3):221-7.
•
Buxman K. Humor in critical care: no joke. AACN Clinical Issues. 2000; 11:120-7.
References
•
Haakana M. Laughter in medical interaction: from quantification to analysis and back. Journal of
Sociolinguistics. 2002; 6:207-35.
•
Suchman AL, Roter D, Green M, Lipkin M Jr. Physician satisfaction with primary care office visits.
Collaborative Study Group of the American Academy on Physician and Patient. Medical Care.
December 1993; 31(12):1083-92.
•
Brody DS, Miller SM, Lerman CE, Smith DG, Lazaro CG, Blum MJ. The relationship between patients'
satisfaction with their physicians and perceptions about interventions they desired and received. Medical
Care. November 1989. 27(11):1027-35.
•
Luallin, M.D., Sullivan, K.W. The Patient’s Advocate: A Six Part Strategy for Building Market Share.
Group Practice Journal. July/August 1998; pp. 13-16.
•
Desmond, J. National Committee on Quality Assurance review of managed care organizations,
communicating with today’s patients. 0-7879-4797, 2000, p.9.
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