leo psoriasis academy 2015€¦ · •psoriasis is a long-term condition that requires patients to...
TRANSCRIPT
LEO Psoriasis Academy 2015
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Communication style 28 August 2015
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The communication challenge
◦ Doctors perform 200,000 consultations in a
professional lifetime
◦ For an effective interview, doctors need to be able to integrate:
• Knowledge
• Communication skills
• Problem solving
• Physical examination
◦ How we communicate is as important as what we say
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Effective communication in healthcare
◦ ‘HCPs [and nurses] are more than a passive conduit of medical
information for their patients. They are interpreters and shapers of their
patients’ health and full partners in their
long-term health status’ - Travaline et al. J Am Osteopath Assoc 2005;105:13–18
◦ ‘Most complaints (70%)…deal with problems of communication not with
clinical competency’ - Meryn BMJ 1998;316:1922
◦ There are two experts in every consultation: The HCP, an expert in the
disease, and the patient, an expert in their own illness and how it affects
them. - Tuckett et al. Meeting between Experts. Tavistock, 1985
◦ ...a skilled healthcare communicator recognises this
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Why does your communication style matter?
◦ Psoriasis has a huge, lifelong impact on patients
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Why does your communication style matter?
◦ Effective communication has a profound effect on patient adherence
• Psoriasis is a long-term condition that requires
patients to engage in self-management
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Two-agenda model for person-centred communication
Differential
diagnosis
Stewart et al. Patient-Centred Medicine. Radcliffe, 1995
HCP agenda Patient’s agenda
Personal
understanding
◦ Signs
◦ Symptoms
◦ Investigations
◦ Feelings
◦ Ideas
◦ Function
◦ Expectations
PATIENT
Disease Illness
Integrated Understanding
Management Plan
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◦ Signs
◦ Symptoms
◦ Investigations
◦ Feelings
◦ Ideas
◦ Function
◦ Expectations
PATIENT
Disease Illness
Stewart et al. Patient-Centred Medicine. Radcliffe, 1995
Two-agenda model for person-centred communication
Differential
diagnosis
HCP agenda Patient’s agenda
Personal
understanding
Integrated Understanding
Management Plan
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Communication skills and steps to be achieved in the consultation 1. Initiating the session (establishing the initial rapport
and identifying the reasons for the consultation)
2. Gathering information (exploring the problem,
understanding the patient perspective, providing
structure to the consultation)
3. Building the relationship (developing rapport and
involving the patient)
4. Exploration and planning (providing the appropriate amount
and type of information, aiding accurate recall and
understanding, achieving a shared understanding and
planning)
5. Closing the session
Silverman et al. Skills for Communicating with Patients. Radcliffe Medical Press, 1998
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Communication skills and steps to be achieved in the consultation 1. Initiating the session (establishing the initial rapport
and identifying the reasons for the consultation)
2. Gathering information (exploring the problem,
understanding the patient perspective, providing
structure to the consultation)
3. Building the relationship (developing rapport and
involving the patient)
4. Exploration and planning (providing the appropriate amount
and type of information, aiding accurate recall and
understanding, achieving a shared understanding and
planning)
5. Closing the session
Silverman et al 1998
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HOW DO YOU ENGAGE DIFFERENT PATIENT TYPES?
Challenge 1
Refer to Patient profiling
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Interactive exercise 1
On your tables you have the patient profiles
Discuss with your colleagues:
◦ How to build rapport and establish a therapeutic relationship with each patient type
◦ What are the challenges associated with each patient profile?
Feedback
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Building rapport and relationship
◦ Non-verbal behaviours – eye contact, facial expression, posture, movement
◦ Verbal behaviours – vocal cues, eg rate, volume, intonation.
◦ Non-judgemental acceptance
◦ Use of empathy – acknowledging patient’s views and feelings
◦ Providing support
◦ Sensitivity
◦ Sharing thoughts
◦ Genuineness
◦ Physical examination – seek consent, explain process
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Gathering information
◦ The appropriate use of questions
◦ Active listening
◦ Picking up cues into the patient agenda
◦ Summary and checking
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Gathering information
1. The appropriate use of questions
◦ Open, closed, focused
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Gathering information
2. Active listening
◦ Non-verbal – leaning forward, nodding, encouraging the patient to tell their story. Not interrupting
◦ Verbal – facilitation, clarification and summary. Listening with an intent to understand
◦ The first 2 minutes are key
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Gathering information
3. Picking up cues into the patient agenda
◦ Verbal cues – comments, fears, ideas, expectations. Expressed by patient or asked directly by physician
◦ Non-verbal cues – emotions, facial expressions, eye contact, body language
◦ Clarifying reasons for visit and worries (not necessarily the first problems expressed)
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Gathering information
4. Summary and checking
◦ Summarise to check own understanding of what has been heard
◦ Clarify with the patient
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HOW TO GATHER INFORMATION?
Challenge 2
Refer to Patient profiling
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Interactive exercise 2
◦ As a group, think of a patient you have met who fits with one of the patient profiles
◦ Choose one person on your table to act as physician – one person role plays as their patient, the other physicians observe
◦ Role play the first 3/4 minutes of the consultation
◦ Give feedback
◦ Change roles if time permits
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Gathering information
The appropriate use of questions
◦ Open, closed, focused
Active listening
◦ Non-verbal – leaning forward, nodding, encouraging the patient to tell their story. Not interrupting
◦ Verbal – facilitation, clarification and summary. Listening with an intent to understand
◦ The first 2 minutes are key
Picking up cues into the patient agenda
◦ Verbal cues – comments, fears, ideas, expectations. Expressed by patient or asked directly by physician
◦ Non-verbal cues – emotions, facial expressions, eye contact, body language
◦ Clarifying reasons for visit and worries (not necessarily the first problems expressed)
Summary and checking
◦ Summarise to check own understanding of what has been heard. Clarify with the patient
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Coffee break
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Communication skills and steps to be achieved in the consultation 1. Initiating the session (establishing the initial rapport
and identifying the reasons for the consultation)
2. Gathering information (exploring the problem,
understanding the patient perspective, providing
structure to the consultation)
3. Building the relationship (developing rapport and
involving the patient)
4. Exploration and planning (providing the appropriate
amount and type of information, aiding accurate recall
and understanding, achieving a shared understanding
and planning)
5. Closing the session
Silverman et al 1998
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Information sharing
...the most challenging part of the consultation
◦ Patients complain about the level of information they
receive more than almost any other issue
◦ Often information priorities of healthcare professionals
don’t match those of patients
‘Patients place the highest value on information about prognosis,
diagnosis and causation...(healthcare professionals) overestimate the
patient’s desire for information concerning treatment and drug
therapy’1
◦ Retention of information can be a problem
‘Patients only retain 50% of the information given’2
1. Kindelan and Kent. Psychol Health 1987;1:399–409; 2. Ley. Communicating with Patients: Improving Communication, Satisfaction and Compliance. Croom Helm, 1988
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Information sharing
...a key part of the consultation
◦ Person-centred communication influences patients’ health
through the feeling that common ground was achieved with
the physician
◦ Person-centred practice has been shown to improve health
status and increased the efficiency of care by reducing
diagnostic tests and referrals1
◦ The sharing of information and engagement of the patient
is essential when trying to improve adherence
1. Stewart et al. J Fam Pract 2000;49:796–804
Keeping it ‘SIMPLE’
S Simplify the regimen
I Impart knowledge
M Modify patient beliefs and human behaviour
P Provide communication and trust
L Leave the bias
E Evaluating adherence
Atreja et al. MedGenMed 2005;7:4
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Ensuring adherence
2009 study: meta-analysis of 106 studies
Zolnierek and DiMatteo. Med Care 2009;47:826
Relationship between compliance and communication
both strongly positive and significant
19% higher risk of non-adherence among patients whose physician was a poor communicator
Non-adherence was 1.47 times greater (standardised relative risk)
among individuals whose physician was a poor communicator
Odds of adhering are 2.16 times greater (standardised odds ratio) if the physician is a good communicator
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Ensuring adherence
◦ Intentional non-adherence
◦ Reject diagnosis or treatment
• Anger at having the disease
• Concern about treatment side effects
• Misconceptions about severity of condition
• Financial decision
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Ensuring adherence
◦ Dealing with intentional non-adherence
• Ask open questions
• Encourage discussion
• Identify specific concerns
• Involve patients in treatment decisions
• Ensure they understand severity of condition
• Aim to prioritise treatment among conflicting financial
demands…raise the issue
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Ensuring adherence
◦ Non-intentional non-adherence
• Forgetfulness
• Physical inability (including age-related)
• Misunderstanding
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Ensuring adherence
◦ Dealing with non-intentional non-adherence
• Understanding treatment regime is key
• Keep it simple and specific
• Suggest a time trigger
• Ask a relative to come to the consultation
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HOW DO YOU KNOW HOW MUCH INFORMATION TO GIVE?
Challenge 3
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Interactive exercise 3
◦ Review the patient profiles. Consider the following questions with reference to improving patient adherence:
1. Can you predict how much information each profile might require? 2. Can you predict what type of information each profile type might find
useful?
3. Can you predict the level of involvement in treatment decisions each profile type would prefer?
◦ With each of the above questions, consider:
• How would you test this and monitor your progress during the
consultation?
• Would communication tools help?
4. How would you motivate behaviour change?
Toolkit
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Putting it into practice
◦ Find out what the patient already
knows and what information they
would like
◦ Give information in simple chunks
using patient language
◦ Pick up on patient cues about how
much involvement they would like
◦ Patient personality type will influence
their level of involvement and
information needs Toolkit
Patient profiling
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Putting it into practice
◦ Involve the patient in making choices
rather than giving directives
◦ Reactive explanations, using patient
explanatory models
◦ Explore options and discuss risk
Patient profiling
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Tips to improve information retention
◦ Logical sequence to the information
◦ Repeat and summarise
◦ Check understanding
◦ Diagrams and written materials
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Encouraging lifestyle change
Motivational interviewing
◦ Feedback – after assessment of the patient’s current condition
◦ Responsibility – emphasis on personal responsibility for change
◦ Advice – clear advice that things need to change
◦ Menu – providing alternative strategies to help the patient change
◦ Empathy – active understanding of the patient’s experience
◦ Support self-efficacy – encouraging patient to believe they can change
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Encouraging lifestyle change Stages of change
Pre-contemplation
Contemplation
Preparation
Action
Maintenance
Prochaska and DiClemente. Toward a Comprehensive Model of Change. Springer, 1986
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Encouraging lifestyle change Stages of change
Maintenance
Prochaska and DiClemente. Toward a Comprehensive Model of Change. Springer, 1986
Pre-contemplation
Contemplation
Preparation
Action
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Encouraging lifestyle change Stages of change
Pre-contemplation
Contemplation
Preparation
Action
Maintenance
Prochaska and DiClemente. Toward a Comprehensive Model of Change. Springer, 1986
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Encouraging lifestyle change
◦ Pre-contemplation – raise awareness
◦ Contemplation – give reasons for change and boost
self-efficacy
◦ Preparation – clarify goals and plan a course of action
◦ Action – provide help and advice to guide towards change
and prevent relapse
◦ Maintenance – reinforce the benefit of change and identify
resources to maintain goal
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Summary
◦ A person-centred approach to the consultation can greatly
improve patient understanding, the sharing of information
and hence adherence
◦ It’s important to consider the various stages of the
consultation and the skills required at each stage
◦ To meet the needs of different individuals, it’s important to
be able to adapt your consultation style and the quantity
and quality of information you give
◦ Individuals have different preferences for involvement in
healthcare decisions
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The last word
Adapt your style…
…and if you remember only one thing, remember the first 2 minutes of a consultation are key
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Communication style handouts
27 October 2015
p. 045
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Interactive exercise 3
◦ Review the patient profiles. Consider the following questions with reference to improving patient adherence:
1. Can you predict how much information each profile might require? 2. Can you predict what type of information each profile type might find
useful?
3. Can you predict the level of involvement in treatment decisions each profile type would prefer?
◦ With each of the above questions, consider:
• How would you test this and monitor your progress during the
consultation?
• Would communication tools help?
4. How would you motivate behaviour change?
Toolkit
Interactive exercise 3
How would you motivate behavioural
change?
Can you predict how much information each profile
might require?
Can you predict what type of information each
profile might require?
Can you predict the level of involvement in
treatment decisions each profile type might
require?