Patient Centered Communication

Patient Centered Communication Mobeen H. Rathore, MD, CPE Professor and Associate Chairman Department of Pediatric University of Florida Chief Pediatric Infectious Diseases and Immunology Wolfson Children’s Hospital Jacksonville, Florida

Disclosure • I have the following financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity • Research Support from: Gilead • Speakers’ Bureau for: GSK/Sanofi • Consultant for: GSK/Cerexa • It is my obligation to disclose to you (the audience) that I am on the Speakers Bureau for GSK and Sanofi. However, I acknowledge that today’s activity is certified for CME credit and thus cannot be promotional. I will give a balanced presentation using the best available evidence to support my conclusions and recommendations. • I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

Evidence for Benefits of Better Communication Skills • Better Patient Outcomes-Improved quality • Increased patient and physician satisfaction • Increased adherence; less tests and referrals • More appropriate medical decisions • Better management of chronic conditions • Fewer medical errors-Dec malpractice claims Hughes CM. Drugs & Aging. 21(12):793-811, 2004. Suarez-Almazor ME.. Current Opinion in Rheumatology. 16(2):91-5, 2004 Mar. Lussier MT. Richard C..Canadian Family Physician. 51:37-9, 2005 Jan.

Evidence for Benefits of Better Communication SkillsArch Intern Med. 1994:154;1365 • Decreasing chance of law suits by avoiding • Perceived problems in patient-physician relationship • Poor delivery of information – even bad news • Ineffective or absent apology • Feeling of desertion • Devaluing patient view/concern • Failing to understand patient/family perspective

Communication Challenges What are your hot buttons? Need to know them!

Hot Button: Patients who….. • Want everything done now • Come with a diagnosis in mind and want you to confirm • Graduated from University of Google • Set you up • Manupalative • Rude • Unreasonable expectations • On cell phone when you are trying to see them • Non-Adherent

IMPRESSIONS ABOUT PHYSICIANS • Too busy to listen and too distant to care • Technologies taking precedence over the art of medicine (read: listening) • Using sophisticated science without sophisticated communication skills • Deep scientific knowledge important & abundant; effective communication skills critical & lacking • Educators not trained in communication skills • ACGME recognizes and requires trainees to demonstrate competence in communication • IOM desirable physician attribute

Patient Centered Communication not new • “The secret of the care of the patient is in caring for the patient” (Peabody FW. JAMA 1927;88:877-882) • Focus on the person with the disease rather than disease itself (Kleinman A, et al. Ann Inter Med. 1978; 88: 251:258) • Patient Centered Care: Focusing on understanding the needs of the individual patient and tailoring specific treatment to them (IOM)

Why Improve Communication • Half of what we know in medicine today is wrong, the challenge is we don’t know which half • Medicine is the science of uncertainty and the art of probability – Osler • Medicine is science of certainty to the degree of current available evidence ……until evidence to the contrary becomes available. • Uncertainty isn’t going away, learn to manage it • In every era of medicine those who focused on treating the patient and not just the disease were successful

Physician Perspective on Communication • 250,000 patient encounters during career • 25% encounters described as frustrating • 50% of these described as dysfunctional • Poorly equipped to deal with the many demands placed on them • The behaviour/personalities of certain patients often strain inadequate skills • Personal, social, and cultural “baggage” often interfere with communication

Patient Perspective on Communication • 80% feel their doctors are too busy to listen to their complaints • 27% state their primary care physician failed to address their main concern • 32% state that their sub-specialist failed to address their main concern • “That doctor is probably a pretty good doctor, but you can’t talk to him. He didn’t seem to want to know what I was worried about.” “Tell me About Yourself”; The Patient Centered Interview. Annals of Internal Medicine. Vol. 134. No. 11. June 2001. pp. 1079-1081.

Physician Patient CommunicationSchwartz Center for Compassionate Healthcare, Mass Gen Hospital • Survey of 800 patients and 500 doctors • 48% patients felt they played no role in decision making for their care • 29% patients did not know which Doctor was in charge of there care • 81% of patients and 71% of doctors reported that outcomes were better with better communication

Communicating Effectively • Communication skills are essential to: • Physician-pt relationship, Daily interpersonal contact • “Art of medicine” Hard science demonstrating clinical outcome benefits • Centered on the patient’s needs NOT DISEASE-CENTERED and NOT DOCTOR-CENTERED • It is a skill that can be mastered • Engage the patient to play a larger role • Help the physician to manage time and improve efficiency and effectiveness” “Tell me About Yourself”; The Patient Centered Interview. Annals of Internal Medicine. Vol. 134. No. 11. June 2001. pp. 1079-1081.

The Skill of Reflective Listening • Excellent starting point for beginning a dialogue with a complex patient. - Attitude: curious, non-judgmental, seek to understand the patient’s perspective - Skill: Ask open ended questions and actively listen. • This attitude will often take the patient by surprise.

Relationship Building Information Gathering Patient Education The Patient-Centered Interview

The Physician-Centered Interview • Traditional history-taking and interview - A manual of laundry lists • Hundreds of items pertaining to organ systems • Clinician expert on disease • Patient expert of her/himself • On the average, physicians interrupt the patient 18 seconds after the patient begins to speak1. 1.Lipkin M, Putnam S, Lazare A. eds. The Medical Interview. Clinical Care, Education and Research. NY. Springer-Verlag.1995.p.531.

Patient Centered Interview • Consider each Pt encounter like a discussion with a specialist, an expert or a colleague you have invited to take care of a patient • You and your team are the expert/specialist in the disease • Patient/Family is the expert on the patient. • Think of the patients’ specialty as “Patientist” • Seek patient’s input and perspective

The Patient-Centered Interview • Patients who were not interrupted rarely took more than to complete their list. • Patients who were not interrupted never took more than to complete their list. one minute three minutes

Why not interrupt? • We lose potentially relevant information: - We change the course of the story • We jump to conclusions: Premature hypothesis testing (Diff Diagnosis) • Patients need a period of uninhibited talk at the beginning of the interview to express their concerns IT DOESN’T TAKE LONGER!

Information Gathering Relationship Building Patient Education The Patient Centered Interview

OARS (Information Gathering) • Open ended questions • Affirmations • Reflective Listening • Summaries

Information Gathering: Eliciting Data Efficiently and Accurately • Patients want to give information about their concerns. • Begin with a comprehensive inquiry about the patient’s entire list of concerns before collecting details on any one complaint • This ultimately saves time and assures focus on key issues.

Information Gathering:Seek the Patient’s Concerns • When? At the beginning of the visit • How? Comprehensive “What Else?” examples… “What else has concerned you?”,“Are you worried about anything else?”,“Tell me more”; • Why? Minimize “Oh by the way” at end of visit • Clarify: “Help me understand what you mean by..”,“Let me review what I think I heard”,“Let’s summarize so we can both be sure I have the story straight” • Facilitate: “Tell me more”, Attentive listening, Echo the patient’s last few words

Information Gathering: Negotiating Priorities & Joint Agenda Setting • Example: I’m not certain we can cover all our concerns. “We agree that A is important. I also want to address B, and you expressed concern about C. Where should we start?” • Patient and Physician: Negotiate priorities together; share control; establish concept of limits • When patients believe their concerns have been heard, they are more willing to accept the clinician’s recommendations otherwise dissatisfaction and poor compliance result.

Four Habits ModelAlderson P, Montgomery J: Health Care Choices:Making Decisions with Children. 1996 • Opening Ceremony (Invest in the beginning): plan visit, develop rapport, elicit concerns • Main Event: Elicit patient’s perspective, ask for specific requests, patient’s thoughts • Closer: Demonstrate empathy, understand patient’s emotions, convey verbally and non-verbally • Grand finale (Invest in the end): shared decision making, follow-up plan, education

Kalamazoo Consensus StatementPediatrics. 1982; 70:396 • Build relationship (Reflective listening, Partnership, Empathy, Respect, Support) • Open the discussion (Reflective listening, agenda setting) • Gather information (patient centered interview) • Understand patient’s perspective (empathy) • Share information (partnership, respect) • Reach agreement (Agenda setting, priortizing) • Provide closure (Partnership, Support)

The Patient-Centered Interview CONNECTING

Success of Patient Encounter • Physicians: Correct diagnosis and treatment plan is key • Patient: Connecting with physician is key • To make an alliance with patient connecting is key: listen, recognize and respond

CONNECTINGRelationship Building • Recognize Patient’s feelings and emotions: • Anger, • fear , • sadness, • anxiety, • uncertainty • Respond with a supportive statement using “PEARLS”

CONNECTINGRelationship Building P = PARTNERSHIP E = EMPATHY A = APOLOGY R = RESPECT L = LEGITIMIZATION S = SUPPORT

PARTNERSHIP P E A R L S • Patient and physician workingtogether to correctly define the issues and solve problems jointly… • “Let’s tackle this together.” • “We can do this.”

EMPATHY P E A R L S • Understand the patient’s feelings andcommunicate that understanding to the patient. • Requires: • Listening • Wanting to understand: walk in his/her shoes • Communicating… • “That sounds hard.” • “You look upset.” • Express understanding of how patient feels… • “Let me see if I have this right . . .”

How to elicit empathy? • How is everything going today? • You must be exhausted staying up with Johnny all night • How are you feeling today? • Are you scared (anxious, upset…)? • It is OK to be scared. • I would be scared too if I did not know what will happen today? • No one likes shots, it is OK to cry.

APOLOGY/ACKNOWLEDGE P E A R L S • Acknowledge patient’s frustrations/anxiety • Apologize for the situation • Take personal responsibility and apologize when appropriate… • I am sorry we can’t get everything done today and tomorrow. Let’s try to do the best we can • I’m sorry I was late • I am sorry your call was not returned

RESPECT P E A R L S • Demonstrate appreciation/value for Pt’s choices, behaviors, special qualities: You have obviously worked hard on this; That was tough; You handled it well, You have obviously researched this problem. Let’s see if I can add to your knowledge • Shared decision making • Empowering the patient/family • Listening to their concerns:non-judgmental • Not “blowing off concerns” • Respectful of everyone’s time

PATIENT CENTERED COMMUNICATION • Consider each pt encounter a discussion with a specialist/expert/colleague you have invited to take care of a patient • You are the expert in the disease • Patient/Family is expert on the patient. • Patients’ specialty as “Patientist” • Seek patient’s input and perspective

LEGITIMIZATION P E A R L S • Concur that patient’s feelings and choices are appropriate… • “Anyone would be (confused, sad, irritated) by this situation.” • “No one likes shots I would be scared/crying too”

SUPPORT P E A R L S • Offer ongoing personal support… • “I’ll stick with you as long as necessary.” • “I’ll be here when/if you need me.” • “Call me if Johnny is not feeling well at night or on weelend”

SUCCESSFUL CONNECTION P E A R L S • Patient feels alliance, safety and trust • Stronger relationship to cope with stresses of illness • Successful Connection = Satisfied Patient and Physician

Agenda Setting Patient Centered Interview Connecting PEARLS Exhaustive “what else” Reflective Listening Communication Tool Box

Patient Centered Communication