Therapeutic relationships and the illusion of communication

Lisa Roberts PhD MCSPArthritis Research UK Senior Lecturer in Physiotherapy / Consultant Physiotherapist

University Hospital Southampton

Plan

• The challenge of communication

• Issues of truth telling

• Current research

• Opening clinical encounters

• Implications for practice

Communication is …..

‘The most important aspect that health professionals have to master’

Weatherall (1998)

Communication

Importance of:

• Verbal communication

• Non-verbal (55-97%)

• Patient-therapist relationship

Poor communication

80% of patients’ complaints arise from a breakdown in communication

Towles BMJ;1998:301-4

Non-specific treatment effect

• Touch

• Showing interest (Hawthorne effect)

• Professionalism

• Actively listening

• Environment

• Technical equipment

• Placebo effect ….

The most important thing in communication is to hear what isn't being said.

Peter Drucker

Why do we tell lies?

• To reduce fear • To tolerate stress • To gain control over uncertainty• Superstition • To enhance well-being • To protect privacy / confidentiality • To help others• To be malicious

Physiotherapists’ perceptions…

…of the most important factors in successful treatment

• patient-therapist relationship

• patients’ resources

More important to success than treatment techniques

Stenmar & Nordholm. Physical Therapy 1994;74:1034-9.

Aim of the pilot study

To measure the content and prevalence of the verbal and non-verbal communication that occur between physiotherapists and patients with low back pain in an outpatient setting.

Roberts L & Bucksey SJ. Communicating with patients: what happens in practice? Phys Ther 2007; 87: 586–94

Roberts & Bucksey Physical Therapy 2007;87(5):586-94

Patients (n = 21) Physiotherapists (n = 7)

Video recording: Initial treatment session (n=21)

Key findings

1. Verbal & non-verbal communication can be measured with valid and reliable tools

2. Affective behaviours were more prevalent among experienced physiotherapists

3. Video camera was perceived to influence communication, planning and treatment

Communication and clinical decision making in low back pain consultations

• Funded by Arthritis Research UK

• 'What communication and clinical decision making takes place in consultations between physiotherapists and people with back pain?'

Patient interview

Home visit

Observation of initial back pain consultation

Physio interview

Wessex Medical Research: Student Innovation Grant 2009

“Piloting an analysis of verbal communication using Synote in consultations between physiotherapists

and people with back pain.”

Christopher WhittleUniversity of Southampton

Synote

http://www.synote.org/synote/

Analysis

• Grounded theory approach

• Data managed through ‘Framework’

27 home visits 25 initial consultations 25 interviews with physiotherapists 25 interviews with patients

Expectations data

• Knowledge:TechnicalLife

• Skills:TechnicalInterpersonal

• Personal attributes:AppearanceManner

Opening questions

• ‘How can I help you today?’

• ‘Do you want to tell me your story’

• ‘I’ve had this referral through. Tell me what’s happened’

• ‘What problem are you having at the moment?’

• How long have you had back pain for?

• It’s your back pain that you’re here for is it?’

• The referral says you’ve got back pain. Is this correct?

• ‘What we’ll do today is just have a bit of a chat about your back pain I believe it is. All right?

Clinical implications

• How do you open your clinical encounters?

• How often do you interrupt your patients?

• Do you tailor your communication to take account of gender and age?

• When was the last time you told a ‘little white lie’?

• Have you spent time evaluating your communication skills?

• How will you maximise your non-specific treatment effects?