Talking the talk: Making the most of your clinical encounters

Lisa Roberts PhD PFHEA FCSPClinical Professor of Musculoskeletal Health & Consultant Physiotherapist

L.C.Roberts@soton.ac.uk

University Hospital Southampton

Outline

‘Communication is the most important aspect that health professionals have to master’ (Weatherall, 1998)

• Obstacles to rapport: small talk and minimising phrases

• History-taking (interruptions)

• Establishing fears and concerns

• Explaining findings

• Reassurance

• Shared decisions

• Making the most of your encounters

Communication and clinical decision making in low back pain consultations:

1) Patients’ expectations

2) Perceptions of diagnosis

Study 3

Feasibility RCT evaluating clinicians’ workshop

Study 1

Cross-sectional: observation(25 pairs)

Study 2

Longitudinal(15 care episodes)

5) Patient involvement in clinical decision-making

3) Verbal & non-verbal communication + interaction

4) Influence on clinical decision-making

Key findings: Mapping the initial consultation

• Mean duration of consultation = 38’59’’ (range 26’21’’–53’16’’)

• Clinician talk comprised 1/2 of the consultation duration

• Patients spoke for approximately 1/3 of the time

• ‘Advice’ constituted 12.5% of the first meeting

• Experienced clinicians demonstrated greater prevalence of talking concurrently and interrupting patients (7.6% vs 2.6%)

Phys Ther 2013; 93(4): 479-491

The clinical consultation

WelcomeHistory taking

Physical examination

Explain findings

Next steps

Closing

Building rapport throughout the encounter

Establishing Rapport

• Genuine / Honesty

• Warmth / Smile

• Introductions

• Proximity & set up

• Posture

• Eye gaze

• Facial expression

• Tone of voice

• Showing interest

Small talk

How are you?

Small talk

Small talk

“It didn’t start off well … you see when people say to me, ‘How are you?’ I hate it when people say that. Because that is like, to me that’s saying, I don’t really care how you are actually, but I’m going to ask out of politeness. It’s, it’s one of those sort of off-hand statements which I try and coach other people not to say. Because I felt like saying, If you want to know I’ll tell you, but you don’t really want to know.”

[44 year male patient]

Small talk

“It didn’t start off well … you see when people say to me, ‘How are you?’ I hate it when people say that. Because that is like, to me that’s saying, I don’t really care how you are actually, but I’m going to ask out of politeness. It’s, it’s one of those sort of off-hand statements which I try and coach other people not to say. Because I felt like saying, If you want to know I’ll tell you, but you don’t really want to know.”

“… It’s one of those statements people should avoid. But you’re better off saying, You look crap! You know what I mean? At least you’re making a statement!”

[44 year male patient]

The clinical consultation

WelcomeHistory taking

Physical examination

Explain findings

Next steps

Closing

Building rapport throughout the encounter

Manual Therapy 19 (2014) 306-10

New consultations: ‘Do you want to just tell me a little bit about your back pain first of all?’

Follow-up consultations: ‘How have you been since I last saw you?’

Interruptions

• Overlap vs interruption

• Patients take on average 92 seconds to explain their problem if not interrupted (Langewitz et al. 2002)

• Physicians give patients 23.1 seconds on average & interrupt nearly half of their patients

• Our study, in 42 initial consultations, physios interrupted the key clinical question in 60%

Journal of Communication in Healthcare 2018

Only

Care with minimising phrases: ‘Just’

PATIENT I think I’ve had um, four… four disturbed nights in the last three weeks, which is a lot better.

PHYSIO Were you woken up just once or twice?

PATIENT Yes, yes.

PHYSIO OK. (Pause)

PATIENT Um. But I still have problems moving in bed. Do you know, when you turn over

PHYSIO Yeah.

PATIENT I can’t lie on my side for very long, I have to lie flat on my back, and as I normally sleep on one side, umm I’m finding that very difficult …

The clinical consultation

WelcomeHistory taking

Physical examination

Explain findings

Next steps

Closing

Building rapport throughout the encounter

Care with minimising phrases: ‘Little / bit’

PHYSIO … A bit tight behind there. (Both laugh).

PATIENT It was very tight behind there. I could feel it really stretching…

PHYSIO I know you’re a little bit stiff in your back, umm and you can feel it as well… Yeah … you note you’re a little bit stiff, don’t you?

PATIENT Yeah I am, very stiff.

PHYSIO Yeah … So umm…

PATIENT Stiff as an old board! (Both laugh)

Care with minimising phrases: ‘Bit tender’

PHYSIO That’s lovely. (Pause). So I know it’s probably going to be a bit tender, is that tender there?

PATIENT Yeah.

PHYSIO OK. Now if you bend forwards from there.

PATIENT Oh, that is agony, just doing that.

Eliciting fears and concerns

• In order to help address patients’ concerns and fears, we first need to be able to identify them

• It is important not to make assumptions – explicitly ask

• Eg. ‘In relation to this back pain episode, is there anything that you’re worried about?’

• Active listening is key: It requires skill to avoid interrupting, have difficult conversations and avoid missing non-verbal cues.

The clinical consultation

WelcomeHistory taking

Physical examination

Explain findings

Next steps

Closing

Building rapport throughout the encounter

Explaining your findings

How do you explain:

• Persistent low back pain?

• Age-related findings on scans? ‘Chronic’

‘Degenerative’

‘Wear and tear’ ….

I’m doomed!

Explaining the ‘normal scan’

• “Your scan is normal”

• “Your back’s fine”

• “Everything’s OK”

• “There’s nothing wrong”

• “No need to worry”

• “Nothing was found”

• “Just a bit of degeneration / wear and tear”…..

Reassurance

• Acknowledge the patient’s pain / distress

• Be supportive (avoiding negative language)

• Give an appropriate explanation (including good prognosis, no serious underlying pathology, stay active)

Affective reassurance

Cognitive reassurance

Satisfaction

Outcomes

Outcomes

The clinical consultation

WelcomeHistory taking

Physical examination

Explain findings

Next steps

Closing

Building rapport throughout the encounter

Shared decision-making

• … Philosophy and process whereby clinicians and patients work in partnership to make choices about care, based on clinical evidence and patient informed preferences.

• Systematic review: 161 definitions31 concepts418 articles

Key: 0=The behaviour is not observed 1= A minimal attempt is made to exhibit the behaviour 2= The behaviour is observed and a minimum skill level achieved3= The behaviour is exhibited to a good standard 4= The behaviour is observed and executed to a very high standard

(Elwyn et al, 2005)

• 12 decision-making items. Rated 0-4.

• Summated & scaled to % ( score = shared decision-making)

• 60% considered minimum competence threshold

The clinician ….

1 …draws attention to an identified problem as one that requires a decision making process

2 … states that there is more than one way to deal with the identified problem

3 … assesses patient’s preferred approach to receiving information to assist decision making

4 … ‘options’, which can include the choice of ‘no action’

5 … explains the pros and cons of options to the patient

6 … explores the patient’s expectations about how the problem(s) are to be managed

7 … explores the patient’s concerns (fears) about how problem(s) are to be managed

8 … checks that the patient has understood the information

9 … offers the patient explicit opportunities to ask questions during decision making process

10 … elicits the patient’s preferred level of involvement in decision making

11 … indicates the need for a decision making (or deferring) stage

12 … indicates the need to review the decision (or deferment).

Findings

• 12 clinicians

• 78 encounters (40 new patients; 38 follow-ups)

• All items mean score = 1 (except item 7 where mean = 0)

Key:

0=The behaviour is not observed1= A minimal attempt is made to exhibit the behaviour 2= The behaviour is observed and a minimum skill level achieved3= The behaviour is exhibited to a good standard 4= The behaviour is observed and executed to a very high standard

(Elwyn et al, 2005)

Findings

• 12 clinicians

• 78 encounters (40 new patients; 38 follow-ups)

• All items mean score = 1 (except item 7 where mean = 0)

• Flemish study 2013: 13 clinicians, 210 observations: mean=5.2%• Couet et al 2013: systematic review (2500 consultations):

mean=23%

Mean OPTION score=24% (Range 10.4–43.8%)

European Spine Journal (2014) 23 (Suppl 1) S13-19

Reflecting on your communication skills …

Audio-record consultations (with permission)

• How do you open your encounters? Is your approach tailored?

• Do you overlap / interrupt your patients?

• Do you use small talk or any minimising phrases?

• How well do your shared decision-making behaviours score?

• Do you give treatment choices (including doing nothing?)

Peer observation & feedback specifically on your communication

Can you run some department training on communication skills & how to maximise non-specific treatment effects?

Some suggestions …

• Feedback via audio-recording (with permission), peer observation, in-service training sessions etc.

• TED questions: Tell me / Explain to me / Describe to me

• Care with small talk and minimising phrases eg. ‘just’, ‘quick’, ‘pop’, ‘bit’, ‘only’ etc.

• Challenge: to make every patient feel valued and special

Communication has the potential to improve the outcome and experience for every care episode.

How will you change your practice based on what you’ve heard today?

The team

• Professor Paul Little

• Professor Maria Stokes

• Professor Cyrus Cooper

• Dr Rose Wiles

• Professor Mark Mullee

• Professor Jen Cleland

• Sally Bucksey

• Chris Whittle

• Emily Chester

• Natalie Cole

• Lucy Jones

• Millie Allen

• Faye Burrow

The staff, patients & managers who made this work possible & funders

https://clipartxtras.com

University Hospital Southampton