Transcript Communicator

Communication Skills Revisited
Sue Dojeiji MD MEd FRCPC
Tuesday, June 7, 2005
Objectives
To appreciate the rationale and
relevance for teaching and learning
communication skills in residency
 To be aware of the communication skills
literature in surgery

Outline

Why revisit communication skills training again!

Review of relevance to Surgery

Evidence behind communication skills training

Information transfer

Consent

Breaking bad news
CPSO
“Inadequate communication between
MD’s and patients or patient’s
families is still the underlying cause
for most of the problems that the
CPSO is asked to investigate”
CPSO 1978
CanMEDS 2000

Canadian Medial Education Directions for Specialists

RCPSC endeavor

Education experts

Societal working groups

Define competencies
Frank, Jason et al Collaboration, Communication, Management and Advocacy: Teaching
Surgeons New Skills through the CanMEDS Project World Journal of Surgery 2003 (27),
972-978.
What do you think?
Which of the following is NOT a CanMEDS 2000
role?
a.
b.
c.
d.
e.
Communicator
Executor
Collaborator
Advocate
Manager
CanMEDS 2000

Identified 7 roles or competencies

Medical expert

Communicator

Collaborator

Professional

Advocate

Manager

Scholar
CanMEDS 2000
Communicator

Establishes therapeutic relationships
with patients and families

Obtains and synthesizes relevant history
and information from patients and
families and the health care team
What Problems?

Discovering the reason for attendance

Doctor-centered information gathering

Inadequate explanation of diagnosis and treatment

Reduced patient adherence

Discordance between patient and physician expectations

Patient feeling ignored and rushed

Lack of empathy or understanding pt perspective
Information Transfer

Explanation and planning

New challenge in communication skills teaching

Not really taught during medical school

Provide accurate amount and type of info

Help patient to retain and recall the info

Help patient to comply with treatment

Shared decision-making

Patient satisfaction
Information Transfer

Interviews of U of O Internal Medicine residents

Daily information transfer

Most junior resident usually

No direction

No feedback

How do we know how good we are????

No complaints

Patient doesn’t cry
Dojeiji et al MRP: Are they as good as they say? 2001
Relevance to Surgery

Body of literature emerging

Recognizing unique needs

Consent for surgical procedures

Increasingly complicated technical procedures

Prognosis with and without surgery

Unexpected surgical outcome

Error

Time constraints
Levinson et al Communication between surgeons and patients in routine office visits. Surgery 1999 (125) 127-34
Relevance to Surgery

AAOS 1998 survey

Patients

Orthopedic Surgeons

Patients rated surgeons highly on technical skills but lower on
communication skills

Surgeons self-rated high on communication

Surgeons rated other colleagues lower
Frymoyer et al Physician-Patient communication: a lost art? JAAOS 2002(10) 95-105
Relevance to Surgery

Average length – 13 minutes

History - 3.5 minutes



Close-ended questions
Physical – 3 minutes

Asked elements of history

Some started with physical (9%)
Education/counseling – ½ of time

Treatment options

+++ info provided

Brief patient questions
Levinson et al Communication between surgeons and patients in routine office visits. Surgery 1999 (125) 127-34
Relevance to Surgery

Informed decision-making

Compared surgeons to primary care physicians

Applied 3 criteria – rigorous to standard

Surgeons had more complete approach

20% of explanations considered complete
Braddock et al Informed decision-making in outpatient practice. JAMA 1999 (282) 2313-2320
Relevance to Surgery

Empathy – how physicians address p/s concerns

Labeled emotional and social cues

Primary care and surgeons

½ of visits contained at least 2 cues

Majority embedded in health problem

Missed opportunity (79% primary care; 62% surgery)

Visits longer with missed opportunity (2 min)
Levinson et al A study of patient clues and physician responses. JAMA 2000 (284) 1021-1027
Relevance to Surgery

Reasons for missed opportunity

Physician discomfort

Can’t fix it

Little training in empathic training



Acknowledge patient feelings
Concern about increased time of interview
Study showed repetition of concern if not
acknowledged (i.e., increased time)
Underlying Premises

Communication is a core clinical skill

Communication is a learned skill

Experience is a poor teacher

Observation is not enough

Not just being nice/good personality
What do you think?
On average, how often are patients noncompliant with their medications?
a. 5%
b. 10%
c. 25%
d. 40%
e. 50%
Evidence Based Communication

Patient understanding

Patient recall

Patient adherence/compliance

Patient satisfaction

Outcome

Psychologic well-being

Protection against malpractice claims
Information Transfer
To improve patient satisfaction, adherence and
outcome:

Clear information

Easy to understand

No medical jargon

Mutual expectations

Active patient role

Non-verbal communication (facilitation)
What do you think?
What percentage of information do your
patients remember as soon as they leave
the doctor’s office?
a. 10%
b. 25%
c. 40%
d. 50%
e. 60%
Information Transfer
Tips for improving understanding and recall:

Categorization

Sign-posting

Summarizing

Repetition

Diagrams

Write it down
Information Transfer Tips
Categorization

“We have 3 ways to manage your mild carpal
tunnel syndrome; first is a night-time splint;
second is an anti-inflammatory; third is a
cortisone injection”

“Lets talk about the splint…”
Information Transfer Tips
Signposting
 “We’ve talked about the splint (option
1), lets talk about the anti-inflammatory
(option 2)…”
Information Transfer Tips
Summarizing

“So again, the options are the splint,
the medication and the cortisone
injection”

“What do you think of those options?”
Information Transfer Tips
Repetition

Either you or the patient repeats at the end
of the interview

Can aid recall by 30%

“So what are those things we’re going to do
for the carpal tunnel syndrome again?

Sue’s favorite: “I’m testing the resident..”
Information Transfer Tips
Diagram/Model
 “Here’s a picture of your hand looking
at your palm. These are muscles and
bones. Here is the nerve that going
from your forearm to your hand. It
goes through a tunnel made of bone …”
Information Transfer Tips
Write it down

Good strategy for complex plan

Good strategy if cognition a concern

Good if you’re explaining a procedure to
the patient – they can keep the picture
for reference and questions
Information Transfer


Questions?
Practice:

3 people




1 doctor, 1 patient, 1 observer
Explain a common surgical procedure
Use 2 strategies learned today
Provide feedback




Things did well
Things to improve
Things to include next time
Stop altogether
Consent

Autonomy



patient’s right to make free decisions about
health care
right to accept or refuse treatment
Respect for persons


health professionals refrain from doing
unwanted interventions
foster patient control over lives
Consent

autonomous authorization of a medical
intervention by individual patients

implicit or explicit

three aspects:

disclosure

capacity

voluntariness
Consent
Disclosure (informed consent)

provide relevant information

frequent or serious adverse events

can’t withhold information because you
think it would lead to suffering
Informed Decision Making
Braddock et al JAMA 1999 (282) 2313-2320

Basic




Complex
Active patient role

In addition to basic
Discussion of what is at
issue; nature of the
decision

Discussion of alternatives

Pros and cons

Exploration of patient
preference

Discussion of
uncertainties with
decision
Assessment of patient
understanding
Consent
Capacity
–
–
–
patient understands information
patient appreciates consequences of
actions
understand different options
Consent
Voluntariness

patient’s right to make decision freely

no force, coercion or manipulation
Practical Approach to Consent

Outline why procedure needs to be done

Consequences on not doing procedure

Review alternatives and why recommendation made

Review the procedure generally

Explain magnitude in terms patient can understand

eg as serious as open heart surgery

Complications and their likelihood of happening

Brief summary

Patient questions
Summary

Ideal plan is worthless if patient won’t follow

Think first what is best medically

Assess patient expectations

Propose a strategy

Monitor its effect

Reassess with patient
Consent


Questions???
Practice in small groups

3 people




1 patient, 1 doctor and 1 observer
Vascular surgery case – see handout
DNR case – see handout
Provide feedback




Things did well
Things to improve
Things to include next time
Stop altogether
Breaking Bad News
Breaking Bad News

special form of explaining and
developing plan

“truth with tenderness”

the words you say will change the life of
the patient forever
Introduction

breaking bad news is inescapable

daily basis

rarely taught formally in clinical training

guidelines now exist - no perfect approach

improve the right/wrong ratio

common faults: common courtesy, failures in
listening, acknowledging patient needs
Should we tell the truth?

Until a few decades ago - not done

1950’s - 90% MD did not tell of cancer dx

published methods for evasion

“the truth may be damaging”

50-97% want to know the truth

96% want to know cancer diagnosis

85% what to know life expectancy

legal and ethical obligation

“how to tell?”
So what is bad news?

Examples in our environment

Reflection on recent situation



Approach/preparation
Outcome
Was it what you expected?
So what is bad news?

“any news that drastically and negatively alters the patient’s
view of his/her future”

depends on what the patient already knows

impact depends on the gap or mismatch:

patient expectations and medical/clinical reality

need patient expectations to judge impact

don’t assume anything
Buckman, R. How to Break Bad News – A Guide for Health Care Professionals. John Hopkins University Press. 1992
Mismatch Grid
Medical Condition
Actual (Reality)
Perceived (Pt)
Not Serious
Serious
X
X
Outcome
Match
Reassure pt
Actual (Reality)
Perceived (Pt)
X
X
Match
Patient ill
Actual (Reality)
Perceived (Pt)
X
Mismatch
Unaware/denial
Actual (Reality)
Perceived (Pt)
X
X
X
Mismatch
Patient anxious
Why is it difficult?
Social factors – loss of health
 Patient factors – reaction
 Doctor/clinician factors




Don’t like to inflict pain
Sympathetic pain
Fear of being blamed
Shooting the messenger (symbol of authority)
 Doctor at fault for deterioration

Why is it difficult
Other fears:
 Fear of untaught
 Fear of eliciting reaction
 Fear of saying “I don’t know”
 Fear of expressing emotions
 Ambiguity of “I’m sorry”


sorry for you (sympathy)
sorry I did this to you (apology)
Breaking Bad News

S etting

P atients perception

I nvitation from patient to give information

K nowledge

E xplore emotions/empathize

S trategy and summary
Buckman, R. How to Break Bad News – A Guide to Health Care Professional. Toronto: University
of Toronto Press, 1992
Setting

seated

quiet

eye contact

listen
Patient Perception

what they have been told

listen to level of comprehension

note discrepancies between fact and
perception
Invitation

any specific concerns or questions

how much detail do they seem to want
to know
Knowledge Giving

follow their lead - start where they
finished off

use simple language

check understanding

respond to patient’s reactions
Explore Emotions and Empathize

identify the emotion

identify the cause

eg. It must be very frustrating to be waiting
so long to get answers

be empathetic even if you don’t agree with
the patient
Strategy and Summary

assess patient expectations

propose a strategy

assess response to the plan

agree on plan

define next steps
Breaking Bad News video
Final Thoughts