the impact of healthcare communication on ......martin von fragstein, jonathan silverman, annie...

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



@OCPHDeakinnOCPHDeakin

CENTRE FOR ORGANISATIONAL CHANGE IN PERSON-CENTRED HEALTHCARE

EACH


CENTRE FOR ORGANISATIONAL CHANGE IN PERSON-CENTRED HEALTHCAREDeakin University CRICOS Provider Code: 00113B


PREMISE 1

Medical education cannot ignore the central importance of

Effective clinical communication

High quality healthcareto


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



NATIONAL AGENDA



RESEARCH INTO CLINICAL

COMMUNICATION

More effective interviews:

accuracy

efficiency

feel more supported

Enhanced patient and health professional satisfaction

Improved health outcomes for patients


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


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


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


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)


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)


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)


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%


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)


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)


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)


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)


Goal that patient would like doctor to make number one priority


• knowledge

• communication

• physical examination

• problem-solving

Clinical competence –

the ability to integrate:


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


•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


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


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


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


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


RESPECT AT THE CENTRE (UK CONSENSUS)

FRAGSTEIN ET AL., MEDICAL EDUCATION 2008


Initiating the session

Gathering information

Physical examination

Explanation and planning

Closing the session

Providing

structure

Building the

relationship


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


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


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


THREE STANDARD QUESTIONS


KEEP IT SIMPLE


RESEARCH PRIORITIES

• Impact of organisation-wide implementation• Diverse metrics


• 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.


OUTCOME OF CLINICAL COHORTS


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


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)


Click to edit Master subtitle style

ORGANISATIONAL INITIATIVES


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

45


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



ACTIVE LISTENING


THANK YOU

[email protected]

For tweeters@petermartinsept@OCPHDeakin@EACH_com@EACH_Aus

the impact of healthcare communication on ......martin von fragstein, jonathan silverman, annie...

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