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Consultation Skills. Dr Sarah Street. Consultation Skills – Why Bother?. Why is it important? Are there problems in communication between doctors and patients? Can clinical communication skills be learnt and do they make a difference? How to learn – skills based approach - PowerPoint PPT Presentation
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Consultation Skills
Dr Sarah Street
Why is it important? Are there problems in communication
between doctors and patients? Can clinical communication skills be learnt
and do they make a difference? How to learn – skills based approach Consultation models
Consultation Skills – Why Bother?
Doctor-patient communication is central to clinical practice◦ Doctors perform about 200 000 consultations in
a professional lifetime Communication is a core skill One of the four essential components of
clinical competence:◦ knowledge base◦ communication skills◦ physical examination◦ problem solving ability
Why is it important?
Communication is not just ‘being nice’ but produces a more effective consultation for both patients and doctors
Effective communication significantly improves:◦ accuracy, efficiency and supportiveness◦ health outcomes for patients◦ satisfaction for both patient and doctor◦ the therapeutic relationship
How we communicate is just as important as what we say◦ communication bridges the gap between
evidence-based medicine and working with individual patients
Why is it important?
45% of patient complaints and 45% of pt concerns not elicited
Most patients want their doctors to provide more information than they do
Doctors overestimate the time they devote to explanation and planning by up to 90%
There are significant problems with patient’s recall and understanding of the information doctors impart
On average 50% of medication prescribed is not taken or taken incorrectly
Problems in communication is the critical factor in >80% of complaints
Are there problems in communication between doctors and patients?
The longer the doctor waits before interrupting at the start, the more likely they are to discover the full spread of issues the patient wants to discus and the less likely it will be that new complaints arise at the end of the consultation
Discovering and acknowledging patients expectations improves patient satisfaction
Does better communication make a difference?
Discovering patient’s expectations leads to greater patient adherence to plans made whether or not those expectations are met by the doctor
Patient satisfaction is directly related to the amount of information that patients perceive they have been given by their doctors
Content skills – what healthcare professionals communicate
Process skills – how they do it Perceptual skills – what they are thinking
and feeling
Types of Communication Skills
An awareness of the structure prevents the consultation from wandering aimlessly and important points from being missed.
Essential when it all goes wrong! Models of the consultation
◦ Disease – Illness Model◦ The Calgary-Cambridge Guide
Consultation Models
PATIENT PRESENTS PROBLEMGathering information
Parallel search of two frameworks
Illness Framework Patients agenda Ideas Concerns Expectations Feelings, Thoughts, Effects Understanding the patients unique experience of illness
Disease framework Doctors agenda Symptoms Signs Investigations Underlying pathology Differential diagnosis
DISEASE ILLNESS MODEL
Integration Explanation and planning in terms the patient can understand and accept
ProvidingStructure
Physical examinationExplanation and planning
Gathering information
Building the relationship
Closing the session
Initiating the session• preparation• establishing initial rapport• identifying the reason(s) for the consultation
exploration of the patient’s problems to discover the biomedical the patient’s
perspective perspective background information - context
providing the correct amount and type ofinformation
aiding accurate recall and understanding achieving a shared understanding:
incorporating the patient’s illness framework planning: shared decision making
• Appropriate point of closure• Forward planning
The Calgary-Cambridge Guide – Expanded FrameworkJ Silverman et al. Skills for communicating with patients. 2005
An example of the interrelationship between content and processGathering information
Process skills for exploration of the patient’s problemspatient’s narrative
question style: open to closed coneattentive listening
facilitative responsepicking up cues
clarificationtime-framing
internal summaryappropriate use of language
additional skills for understanding patient’s perspective
Content to be discoveredthe biomedical perspective (disease) the patient’s perspective (illness)
sequence of events ideas and beliefssymptom analysis concerns
relevant systems review expectations effects on life feelings
background information (context)past medical history
drug and allergy historyfamily history
personal and social historyreview of systems
Initiating the Consultation Gathering Information Building the Relationship Providing Structure Explanation and Planning
◦ Giving Information◦ Shared Decision Making
Closing the Session
Micro-Skills
Establishing a supportive environment Developing an awareness of the patient’s
emotional state Identifying as far as possible all the
problems or issues that the patient has come to discuss
Establishing an agreed agenda or plan for the consultation
Enabling the patient to become part of a collaborative process
Initiating The Consultation Objectives
Preparation◦ Put aside last task, attends to self comfort◦ Focus attention and prepares for this consultation
Establishing initial rapport◦ Greeting, introduction, patient’s physical comfort,
demonstrate interest and respect Identifying the reasons for the patient’s attendance
◦ Opening question◦ Active listening without interruption◦ Screening – check and confirm list of problems or issues◦ Agenda setting
Initiating The Consultation Skills
Reduces uncertainty for patient and doctor May allow for more efficient and effective
use of time Gives more chance for the patient to raise
other concerns and identify the most important concern they wish to explore on this occasion
Encourages negotiation and mutual partnership
Agenda Setting
Listen to the first problem and allow some of the story to come out
Summarise the problems and check you have understood and heard them correctly
Acknowledge the problems; show concern verbally and non-verbally
Ask for any other problems Prioritise the problems – negotiate which
one(s) you will explore on this occasion
Agenda Setting - Strategies
Useful phrases that people have used?
Agenda Setting
‘What’s the first thing you’d like to discuss….?’
‘What’s the one most troubling you….?’ ‘Which one shall we tackle/focus on first/” ‘Which one is the most important to you?’ ‘Let’s start going through them and see
where we get to…” ‘We’ll try to deal with as many problems as
possible….depending on time/how we get on…’
Agenda Setting – Useful Phrases
Exploration of problems◦ Patient’s narrative◦ Question style◦ Listening◦ Facilitative response◦ Clarification◦ Internal summary◦ Language
Understanding the patient’s perspective◦ Ideas and concerns◦ Effects◦ Expectations◦ Feelings and thoughts◦ Cues
Gathering Information
Discuss with your neighbour and feed back to the group.
Useful Phrases to elicit ideas and concerns?
Summarise the problem back to the patient first, then ask:
“What was in your mind......?” “What were you concerned/worried about...?”
(remember that using the word concern helps patient to disclose their worries; most think that their doctor thinks they may be neurotic if they answer to the word worry)
“Was there a particular concern......?” “Tell me what you think the problem is.................have
you any clues or theories.....?” “Have you any ideas about................” “Tell me what you think is the cause............” “Do you have any specific worries about..........” “Tell me what was concerning you.......... is it cancer?”
(go for it) “Is there anybody else you know who has had this
problem?”
Useful Phrases To Elicit Ideas And Concerns:
“Do you think it might be something serious............?” .......... something in particular.....?”
“It’s obviously concerning you........is there any particular reason why?”
“What in your worst moments did you think it was?” “While you have been waiting to see me .....................
what have been your thoughts?” “During those hours when you have been lying awake at
night........what have your thoughts been about the problem?”
“Some people with the same sort of symptoms that you have think that they have something serious like cancer.......is that what you have been thinking?”
“I’m interested in your ideas about.........I’d like to hear about them because I think they will help us both to understand the problem better.....”
“What were your feelings about this?” “I’m sorry to press you, but what was really on your
mind....?”
What has worked well for you?
Useful phrases to elicit expectations?
“What did you think we might ............ “What were you hoping that we might be able to do for
this......... “I’m interested in your thoughts about what might be
helpful before I make any suggestions........ “Were you hoping that I might do something in
particular............ “You’ve obviously given this some thought,.......tell me
what you were expecting..... A good strategy is to give a range of options and then ask
what the patient was expecting from the consultation; “we could try something to help you with the pain; you
might like to see a physiotherapist…..what were you hoping I might do….?”
Useful Phrases To Elicit Patients’ Expectations
If appropriate, pick up a cue: “you said that your knee was giving you a
lot of trouble, I was wondering how that was affecting you……”
“I know that you spend a lot of time working for the WRVS/looking after you disabled husband…..tell me how you are coping……”
To Ask About How A Problem Affects A Person’s Life
Developing rapport to enable the patient to feel understood, valued and supported
Reducing potential conflict between doctor and patient Encouraging an environment that maximises accurate and
efficient initiation, information gathering and explanation and planning
Enabling supportive counselling as an end in itself Developing and maintaining a continuing relationship over
time Involving the patient so they understand and is
comfortable with the process of the consultation Increasing both the doctor’s and the patient’s satisfaction
with the consultation
Building the RelationshipObjectives
Non-verbal communication◦ Demonstrate appropriate non-verbal behaviour◦ Use of computer◦ Picks up patient’s non-verbal cues
Developing rapport◦ Acceptance◦ Empathy and support◦ Sensitivity
Involving the patient◦ Sharing of thoughts◦ Provide rational◦ Examination
Building the RelationshipSkills
Can you think of any ways this has worked well for you?
Any useful tips – please share with the group.
Responding to Cues
‘You appear to be in a lot of pain …’ ‘It sounds like a difficult situation.’ ‘That must be really hard for you.’ ‘Is it something that you want to discuss
with me?’ ‘You seem very …
upset/frustrated/angry/annoyed/ambivalent/negative/elated.’
‘You mentioned about ….’
Responding to Cues; Acknowledging Emotions
Summarise – end of specific line of enquiry/section of the consultation to verify own interpretation of what patient has said, to ensure no important information omitted
Signposting – progress from one section to another using transitional statements; including rational for next section
Sequencing – structure consultation in a logical sequence
Timing – attend to time and keep consultation on task
Providing Structure
Gauging the correct amount and type of information to give to each individual patient
Providing explanations that the patient can remember and understand
Providing explanations that relate to the patient’s illness framework
Using an interactive approach to ensure a shared understanding of the problem with the patient
Involving the patient and planning collaboratively to increase the patient’s commitment and adherence to plans made
Continuing to build a relationship and provide a supportive environment
Information Giving, Explanation And Planning - Objectives
Giving information – checking (Man with Two Brains)
http://www.youtube.com/watch?gl=US&v=3r4rS0yzQ1M
Chunk and check Assess patient’s starting point; prior
knowledge; extent of wish for information Ask what other information would be helpful Give explanation at appropriate times –
avoid giving premature information, advice or reassurance
Providing the correct amount and type of information
Organise explanation – divide into sections, logical sequence
Explicit categorization or signposting Repetition and summarizing Language Visual aids Check understanding
Aiding accurate recall and understanding
Relate explanation to patient’s illness framework: to previously elicited ideas, concerns and expectations
Provide opportunities and encourage patient to contribute
Pick up and respond to verbal and non-verbal cues
Elicit patient’s beliefs, reactions and feelings re information given, terms used; acknowledge and respond
Achieving a shared understanding: incorporating the patient’s perspective
Share own thoughts: ideas, thought processes and dilemmas as appropriate
Involve patient by making suggestions rather than directives
Encourage patient to contribute their thoughts: ideas, suggestions, preferences
Negotiate a mutually acceptable plan Offer choices Check with patient: if plans accepted;
concerns addressed
Planning: Shared Decision Making
End summary Contacting – next steps for patient and
doctor Safety netting Final checking
Closing the Consultation
It is equally important to consider both the medical and patient perspectives of the patient’s problem It is important to gather all relevant information and share an understanding of the issues before moving on to discuss management options A Shared Understanding means that:
◦The Doctor understands the patient’s ideas and views◦The Patient understands the medical aspects and effects of treatment options
In Summary
Improved clinical communication skills leads to more effective consultations and improved outcomes for both patients and doctors
The prize on offer
I hear and I forgetI see and I rememberI do and I understand
Old Chinese proverb
Discovering the reasons for the patient’s attendance 54% of patients’ complaints and 45% of their concerns are
not elicited (Stewart et al. 1979) In 50% of visits, patient and doctor do not agree on the
nature of the main presenting problem (Starfield et al. 1981) Gathering information Both a ‘high control style’ and premature focus on medical
problems can lead to an overnarrow approach to hypothesis generation and inaccurate consultations (Platt & McMath 1979)
Doctors rarely ask their patients to volunteer their ideas and often evade their patients’ ideas and inhibit their expression. Discordance between doctors’ and patients’ ideas and beliefs about the illness is likely to result in poor understanding, adherence, satisfaction and outcome (Tuckett et al. 1985)
Are there problems in communication between doctors and patients?
Explanation and planning◦ Doctors generally give sparse information to
their patients, with most patients wanting more (Waitzkin 1984;Beisecker & beisecker 1990; Pinder 1990)
◦ Doctors overestimate the time they devote to explanation and planning by up to 90% (Waitzkin 1984; Makoul et al. 1995)
◦ Patients and doctors disagree over the relative importance of imparting different types of medical information: patients place the highest value on information about prognosis, diagnosis and causation while doctors overestimate their patients’ desire for information concerning treatment and drug therapy (Kindelan & Kent 1987)
Problems in communication between doctors and patients
Patient adherence◦ On average 50% of patients do not take their
medication at all or take it incorrectly (Meichenbaum & Turk 1987; Butler et al. 1996)
◦ Massively expensive Medio-legal issues
◦ Breakdown in communication between patients and doctors is a critical factor leading to malpractice litigation (Levinson 1994)
◦ Lawyers identified doctors’ communication and attitudes as the prime reason for patients pursuing a malpractice suit in 70% of cases (Avery 1986)
◦ Four communication problems present in >70% of malpractice claims: deserting the patient, devaluing the patient’s view, delivering information poorly and failing to understand patients’ perspective (Beckman et al. 1994)
Problems in communication between doctors and patients
Process of the interview◦ The longer the doctors waits before interrupting at the beginning of the consultation, the more likely they are to discover the full spread of issues that the patient wants to discuss and the less likely will it be that a new complaint arises at the end of the interview (Beckman & Frankel 1984; Joos et al. 1996)◦ The use of open rather than closed questions and the use of attentive listening leads to greater disclosure of patients’ significant concerns (Cox 1989; Wissow et al. 1994; Maguire et al.
1996)◦ The more questions patients are allowed to ask of the doctor, the more information they obtain (Tuckett et al. 1985)
Evidence that communication skills make a difference
Patient satisfaction◦ Greater ‘patient centredness’ in the
consultation leads to greater patient satisfaction (Stewart 1984; Arborelius & Bremberg 1992)
◦ Discovering and acknowledging patients’ expectations improves patient satisfaction (Korsch et al. 1968; Eisenthal & Lazare 1976; Eisenthal et al. 1990)
◦ Patient satisfaction is directly related to the amount of information that patients perceive they have been given by their doctors (Hall et al. 1990)
Evidence that communication skills make a difference
Adherence◦ Doctors can increase adherence to treatment regimens by explicitly asking patients about knowledge, beliefs, concerns and attitudes to their own illness (Inui et al. 1976; Maimen et al. 1988)◦ Discovering patients’ expectations leads to greater patient adherence to plans made whether or not those expectations are met by the doctor (Eisenthal & Lazare 1976: Eisenthal et al. 1990)
Outcome◦ Patients who are coached in asking questions of, and negotiating with, their doctor not only obtained more information but actually achieved better blood pressure control in hypertension and improved blood sugar control in diabetes (Kaplan et al. 1989; Rost et al. 1991)
Evidence that communication skills make a difference