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THE IMPACT OF HEALTHCARE COMMUNICATION ON OUR
HEALTH SYSTEM
Deakin University CRICOS Provider Code: 00113B
Professor Peter MartinChair Clinical Communication and End of Life Care
WHY?CLINICIAN TO CLINICAL COMMUNICATION EDUCATOR
Deakin University CRICOS Provider Code: 00113B
Deakin University CRICOS Provider Code: 00113B
@OCPHDeakinnOCPHDeakin
CENTRE FOR ORGANISATIONAL CHANGE IN PERSON-CENTRED HEALTHCARE
EACH
Deakin University CRICOS Provider Code: 00113B
CENTRE FOR ORGANISATIONAL CHANGE IN PERSON-CENTRED HEALTHCAREDeakin University CRICOS Provider Code: 00113B
CENTRE FOR ORGANISATIONAL CHANGE IN PERSON-CENTRED HEALTHCARE
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PREMISE 1
Medical education cannot ignore the central importance of
Effective clinical communication
High quality healthcareto
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OUTLINE OF OUTCOMES DIRECTLY RELATED TO HC
• Shared Decision Making
• Why do repeated studies show that Drs consume less & different health resources
• Communicating Risk
• Diagnostic Accuracy
• Person-Centred Healthcare
• Patient & Carer Experience
• Adjustment to illness
• Psychological burden in response to illness
• Aiding recall
• Audio recordings of consultations
• Adherence to treatment
• Think of the waste in regards to our precious health $
• Lifestyle modification
• Lifestyle related chronic illness and concepts of motivational interviewing
• In general our skills are poor for such a key skill
Deakin University CRICOS Provider Code: 00113B
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NATIONAL AGENDA
Deakin University CRICOS Provider Code: 00113B
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RESEARCH INTO CLINICAL
COMMUNICATION
More effective interviews:
accuracy
efficiency
feel more supported
Enhanced patient and health professional satisfaction
Improved health outcomes for patients
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Not easy to get the medical interview right
• Don’t start from scratch
• Highly skilled
• Multi-faceted
• Professional challenge
• Closely bound to self-esteem, self-concept, personality
• More complex than simpler procedural skills
• No achievement ceiling
Needs careful attention and cannot be left to chance! The one intervention we all do as H Profs (250,000 times) we have the least training!
Requires thoughtful consideration
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CHOOSING APPROPRIATE TEACHING METHODS
Methods Continuum for Communication Skills Teaching
facilitator-centred learner-centred didactic experiential leading to experiential leading to
“in your head” deeper discussion/understanding change in behaviour
Getting the balance right between
cognitive and experiential
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5. Not picking up and exploring cues
Levinson (2000)
patients gave cues throughout the interview from the opening to the closing minute
doctors only responded to patient cues in 38% of cases in surgery and 21% in primary care
where the cue was missed, half of the patients brought up the same issue a second or third time and in all of these cases, the physician again missed these further opportunities to respond.
Zimmerman et al (2007)
a systematic review, documenting 58 original quantitative and qualitative research articles demonstrating patient expressions of cues and/or concerns, all based on the analysis of audio or videotaped medical consultations.
overall conclusion - physicians missed most cues and adopted behaviours that discouraged disclosure.
Rogers and Todd (2000)
oncologists preferentially listen for and respond to certain disease cues over others
pain amenable to specialist cancer treatment is recognised, other pains are not acknowledged or dismissed
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PROCESS OF THE INTERVIEWthe longer the doctor waits before interrupting at the beginning of the interview, the more likely she is to discover the full spread of issues that the patient wants to discuss and the less likely will it be that new complaints arise at the end of the interview (Beckman and Frankel 1984, Joos et al 1996, Marvel et al 1999, Langewitz et al 2002)
the use of open rather than closed questions and the use of attentive listening leads to greater disclosure of patients’ significant concerns (Cox 1989, Maguire et al 1996, Wissow et al 1994)
picking up and responding to patient cues shortens rather than lengthens visits (Levinson et al 2000)
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PATIENT SATISFACTION
discovering and acknowledging patients’ expectations improves patient satisfaction (Korsch et al 1968, Eisenthal and Lazare 1976, Eisenthal et al 1990, Bell et al 2001)
in cancer patients, satisfaction with the consultation and the amount of information and emotional support received are all significantly greater in those who reported a shared role in decision making (Gattellari et al 2001)
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EVIDENCE BASE PROCESS OF THE INTERVIEW
the longer the doctor waits before interrupting at the beginning of the interview, the more likely she is to discover the full spread of issues that the patient wants to discuss and the less likely will it be that new complaints arise at the end of the interview (Beckman and Frankel 1984, Joos et al 1996, Marvel et al 1999, Langewitz et al 2002)
the use of open rather than closed questions and the use of attentive listening leads to greater disclosure of patients’ significant concerns (Cox 1989, Maguire et al 1996, Wissow et al 1994)
picking up and responding to patient cues shortens rather than lengthens visits (Levinson et al 2000)
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PATIENT RECALL AND UNDERSTANDINGasking patients to repeat in their own words what they understand of the information they have just been given increases their retention of that information by 30%
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ADHERENCE
consultations using a structured exploration of patients' beliefs about their illness and medication leads to improved clinical control or medication use even three months after the intervention ceased (Dowell et al 2002)
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OUTCOMESymptom resolution
resolution of symptoms of chronic headache is more related to the patient’s feeling that they were able to discuss their headache and problems fully at the initial visit with their doctor than to diagnosis, investigation, prescription or referral (The Headache Study Group 1986)
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OUTCOMEPhysiological outcome
providing an atmosphere in which the patient can be involved in choices if they are available leads to less anxiety and depression after breast cancer surgery (Fallowfield et al 1990)
patients who are coached in asking questions of and negotiating with their doctor not only obtain more information but actually achieve better BP control in hypertension and improved blood sugar control in diabetes (Kaplan et al 1989, Rost et al 1991)
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MEDICO-LEGAL ISSUES
Patients of obstetricians with a high frequency of malpractice claims are more likely to complain of feeling rushed and ignored and receiving inadequate explanation, even by their patients who do not sue. (Hickson et al 1994)
Relationship between judgments of surgeons' voice tone and their malpractice claims history. (Ambady et al 2002)
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Goal that patient would like doctor to make number one priority
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• knowledge
• communication
• physical examination
• problem-solving
Clinical competence –
the ability to integrate:
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HOW DO WE CHANGE OUR BEHAVIOUR IN THE
INTERVIEW?
Knowledge is important but only allows you to know aboutcommunication
Experiential teaching is required to know how to communicate
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•Traditional Medical History Model (content)•• Chief complaint • History of the present complaint• Past medical history• Family history• Personal and social history• Drug and allergy history• Systematic enquiry
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Three elements of gathering clinical information
What you think and feel
Perception
Biomedical
Patient’s perspective
What you discuss,
record and present
Content
Clinical reasoning
Feelings
How you communicate
ProcessOpen
Directive
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Confusion between process and content:
How to obtain information v. how to present info
How to obtain information v. how to write down info
Equating problem solving with patient care at the bedside –observation of snippets
The issue of how learner’s are observed (if they are)
GP/psychiatry/psychology v real doctors
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THE KALAMAZOO CONSENSUS STATEMENT
In May 1999, 21 leaders from medical education and professional organizations met to establish a coherent set of essential elements in physician-patient communication to:• facilitate the development, implementation, and evaluation of
communication-oriented curricula in medical education
• inform the development of specific standards in this domain
They reviewed existing models and used a consensus process to reach agreement.
Their model emphasised patient empowerment
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Martin von Fragstein, Jonathan Silverman, Annie Cushing, Sally Quilligan, Helen Salisbury & Connie Wiskin
on behalf of the UK Council for Clinical Communication Skills Teaching in Undergraduate Medical Education
UK consensus statement on the content of communication curricula in undergraduate
medical education
Medical Education 2008
42(11): p. 1100-7
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RESPECT AT THE CENTRE (UK CONSENSUS)
FRAGSTEIN ET AL., MEDICAL EDUCATION 2008
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Initiating the session
Gathering information
Physical examination
Explanation and planning
Closing the session
Providing
structure
Building the
relationship
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exploration of the patient’s problems to discover the:
biomedical perspective the patient’s perspective
background information - context
providing the correct type and amount of information
aiding accurate recall and understanding
achieving a shared understanding: incorporating the
patient’s illness framework
planning: shared decision making
Initiating the session
Gathering information
Physical examination
Explanation and planning
Closing the session
Providing
structureBuilding the
relationship
preparation
establishing initial rapport
identifying the reasons for the consultation
making
organisation
overt
attending to
flow
using
appropriate
non-verbal
behaviour
developing
rapport
involving
the patient
ensuring appropriate point of closure
forward planning
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THE NEED FOR EXPERIENTIAL LEARNING
active small group or 1:1 learning
observation of learners
video or audio recording and review
well-intentioned feedback
Rehearsal
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DURATION OF EFFECTHalf to full day workshop
• Clinical behaviour change 6-12/12
Two to three day residential course
• 3-5 years
Cost and time resource been perceived barrier
• Contrast other key skills like hand hygiene
• Limitation is few have been mandated
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THREE STANDARD QUESTIONS
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KEEP IT SIMPLE
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RESEARCH PRIORITIES
• Impact of organisation-wide implementation• Diverse metrics
Deakin University CRICOS Provider Code: 00113B
• More focus on empowering our community on how to maximise their consultations
• Healthcare Economics• Investment without evidence of return?
• Innovation of “how” to teach this• At scale, over distance, maximal
consolidation of immersive teaching.
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OUTCOME OF CLINICAL COHORTS
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BEFORE AND AFTER DATA
Decrease MET calls• 87 vs 73% (p=0.009)
GOC for those who died at 90 days• 64 to 95% (p < 0.001)
Decrease in 90 day mortality 47 vs 35% (p=0.05)Cancer:• Increase home
• Increased readmission
• Decreased 90 day mortality
Frailty• Decreased MET
• Decreased readmission
• 48 vs 19% (p=0.003)
• No change in mortality
Organ failure• Decreased 90 day mortality
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BEFORE AND AFTER DATA
Documentation
•GoC 50 vs 70% (p=0.001)
•Competence 5 vs 18% (p=0.002)
•Surrogate decision maker 29 vs 46% (p=0.01)
•Values and Goals discussed 16 vs 32% (p=0.005)
•No difference advice or consensus
Clinical choice
Preference for ICU / HDU decreased from 73 to 45% (p < 0.001)
Undecided at 48 hrs post admission increased from 13 to 37% (p < 0.0001)
Agreement of existing ACP 68 vs 100% p=0.04
• (ACP present in low numbers in both cohorts)
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Click to edit Master subtitle style
ORGANISATIONAL INITIATIVES
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EXAMPLES OF INITIATIVES IN US
Breast Care Center, Pittsburgh
• Supports women with newly diagnosed breast cancer by offering DAs and decision support coaching before consultations with physicians
Dartmouth Hitchcock Medical Center, Hanover
• Provides decision support services (Center for Shared Decision Making) to patients across all medical and surgical specialties
• Offers DAs when clinically appropriate tools are available• Supports implementation and training initiativesEverett Clinic Everett
• Provides DAs to patients prior to consultation with orthopedic surgeonsGroup Health Cooperative, Puget Sound
• Provides DAs to patients considering 12 major elective surgeries
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EXAMPLES OF INITIATIVES IN US
Palo Alto Medical Foundation Research Institute
• Has a sophisticated internal marketing campaign to raise awareness of SDM at all levels of the organization and facilitate culture change
• Uses a central resource (Program Navigator) to supplement decision support offered at individual practice sites
Peace Health, Eugene
• Provides decision support coaching to supplement seven DAs in the context of a “medical home” pilot
Stillwater Medical Group and Lakeview Health, Stillwater
• Utilizes Care Navigators to support patients with newly diagnosed breast or prostate cancer, benign prostatic hyperplasia or depression
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ACKNOWLEDGMENTS
Acknowledgements:
• Jonathan Silverman
• Charlie Corke and ”My Values” Project
• Neil Orford and iValidate Team
• EACH
• rEACH, tEACH, yEACH, spEACH
Deakin University CRICOS Provider Code: 00113B
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ACTIVE LISTENING
Deakin University CRICOS Provider Code: 00113B
THANK YOU
For tweeters@petermartinsept@OCPHDeakin@EACH_com@EACH_Aus