The Art & Science of Medicine Ii

The Art & Science of Medicine Ii

COMMUNICATION SKILLS WORKSHOP – OPENING CHANNELS OF COMMUNICATION

Before getting started, a note to the facilitators of this session:

  1. Use this faculty guide as a resource to help facilitate; feel free to focus on aspects you think are necessary for your audience.
  2. Text in small print and italics is for your information and direction.
  3. Please remember to get pre-test questionnaire completed by the trainees prior to session
  4. Encourage comments and interaction from participants, and not just focusing on the faculty guide for generating discussion.
  5. Ensure a confidential and safe environment for practice
  6. Allow “time-outs” if participant wants to think through in the middle of role-play.
  7. Take notes as the participants are role-playing, to be able to give them specific and useful feedback at the end of the role-play
  8. Request specific feedback (both verbal and written on post-test) from participants
  9. Have fun teaching!

Session Outline

oPENING CHannels of communication

Developed by: Ravishankar Ramaswamy, MD and Alicia Williams, MD

TOTAL TIME: 75 min

  1. Objectives (2 min)
  1. Introduction (10 min)
  1. Use of Ice-Breakers (5 min)
  1. Open-ended Questions (10 min)
  1. Active Listening (20 min)
  1. Ask-Tell-Ask (25 min)
  1. Conclusion (3 min)
  1. Objectives

• To understand the importance of effective communication in a physician-patient relationship

• To practice basic communication skills required to obtain a reliable medical and social history from older patients in the clinic / hospital setting

• To become aware of resources available to build on the basic skills gained with ongoing education and competence building

  1. Introduction

Why are communication skills important for doctors?

Elicit trainees’ responses before saying the following:

• Associated with improved adherence to treatment regimen, and improved health outcomes

• Higher satisfaction levels in patients and physicians

• Less likelihood of malpractice suits

One study (JAMA Nov 23/30, 1994 – Vol 272, #20) found no demonstrable correlation between the quality of care by obstetricians and their malpractice claims history; instead found remarkable correlation between patient satisfaction and malpractice claims history. No lapse of medical care quality even when there were malpractice claims.

What are attributes of a good physician?

Elicit trainees’ responses before saying the following:

A good physician must be competent in: BMJ 2002; 325:697–700

• Eliciting the patient's main problems; the patient's perceptions of these; and the physical, emotional, and social impact of the patient's problems on the patient and family

• Tailoring information to what the patient wants to know; checking his or her understanding

• Eliciting the patient's reactions to the information given and his or her main concerns

• Determining how much the patient wants to participate in decision making

• Discussing treatment options so that the patient understands the implications

• Maximizing the chance that the patient will follow agreed decisions about treatment and advice about changes in lifestyle

Why learn about communication skills during residency?

Elicit trainees’ responses before saying the following.

Good time to ask if participants have had any prior training in communication skills

• Not all medical schools have a structured communication curriculum

• ACGME (Accreditation Council for Graduate Medical Education) requires competence in interpersonal and communication skills as 1 of the 6 competencies for residency training.

ACGME requires that:

• Residents demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals.

• Residents be given instruction and experiences to learn the nature and varieties of communication, such as:

– didactic and experiential teaching that addresses verbal and nonverbal communication

– topic areas that address communication with the patient and their family (i.e. delivering bad news, educating patients about their disease, behavior change, end of life issues)

– topic areas that address communication with colleagues (hand off; presenting lectures, leadership)

Activity 1

• Think about situations where you have been faced with challenges when interacting with an older adult, not necessarily your patient.

• What were some of those situations or challenges?

Ask participants to write down some challenging clinical scenarios. These could be used later on in the session for role-play.

  1. Initiating Conversation / Use of Ice-Breakers
  • How do you greet your patient upon entering a room?
  • Do you have a fixed way of introduction?

The first meeting between a patient and a physician can be challenging. Often, both parties make impressions of each other at their first meeting.

  • Start with a formal respectful way of address
  • “Hello Ms. Jones”, “Good morning Mr. Sanchez…”
  • Make eye (and appropriate physical) contact with the patient, and smile

Be aware of the patient’s cultural and ethnic background to determine appropriateness of eye and physical contact during interaction.

  • Address the patient and then everyone else in the room
  • Who all are here with you in the room today?”
  • Ice-breakers
  • What are some ice-breakers you have used?

Discuss any specific ice-breakers participants have used in the past, or seen used.

You may give examples of some that you have used or seen used; i.e. “That’s a nice jacket / shoes you’re wearing”;or asking something specific about their family or pet that you learned from a previous visit.

  • Ice-breakers are known to decrease anxiety and increase comfort in the interaction session. Frequently used at parties, leadership building exercises.
  • Think of an ice-breaker you could use, and practice it.
  1. “Tell me more” / Open-ended Questions
  • A great way to obtain information at the beginning of the encounter
  • Let patients speak and avoid interruption
  • Tell me more about why you are here…”
  • “Tell me more about how this happened..”
  • “Tell me more about your family..”
  • Don’t rush your older patient
  • They might take longer than you think to process questions and respond (could be due to physiologic changes of aging)
  • One study showed that on an average, doctors interrupt patients within the first 18 seconds of an initial interview
  • Open-ended Questions
  • Cannot be answered with simple "yes" or "no“
  • Claim a lack of knowledge of patient’s problems, encourage their de-novo presentation, and frame patients as being active authorities over their own health information
  • What can I do for you today?”
  • Tell me what’s going on?”

Motivational interviewing (MI) is a method of counseling that is directive and client-centered. It encourages clinicians to explore a patient’s understanding and concerns and determine his or her readiness for change. It focuses on the patient’s perception of the problem and encourages the patient to find the solution. This can be enhanced by posing open-ended questions.

  • Closed-ended questions
  • Patients as passive authorities, with “yes” or “no” answers
  • Examples:

“Have you been taking your medicines as we had discussed?”

“I understand you’re having some leg problems?”

  1. Active Listening
  • A communication technique that requires the listener to understand, interpret, and evaluate what (s)he hears.

3 primary elements:

  • Comprehending
  • Retaining
  • Responding
  • Intentionally focuses on who you are listening to, whether in a group or one-on-one, in order to understand what he or she is saying
  • Listen with your ears but also with your eyes and other senses
  • Non-verbally acknowledge points in the speech
  • Can also use phrases like “I see”, “okay”, “uh-huh”
  • As the listener, you should then be able to repeat back in your own words what they have said to their satisfaction
  • This does not mean you agree with the person, but rather understand what they are saying

Activity 2

  • Have the participants break into groups of 2 for role-play, one person acting as the physician, and the other as the patient.
  • They can use any of their own clinical scenarios or ones mentioned in the guide.
  • Assess participants for the skill they choose to practice, like one or more of the following:
  • Ice-breakers
  • “Tell me more…” and open-ended questions
  • Active Listening including responding to the information received
  • Use of simple phrases
  • Body language, eye contact
  • After the role-play session, elicit participants’ feedback on what they did well and what they could improve
  • Give specific feedback on aspects done well, and aspects that could be improved.
  • Allow for an opportunity to practice again, if time permits.
  • Then, have the participants change roles, so as to give the other person a chance to be the physician.
  1. Ask-Tell-Ask

This involves

  1. Checking patient expectations
  2. Sharing information
  3. Inquiring explicitly about the patient’s reaction
  1. Ask patients to describe their understanding of their disorders and treatments

• Ask the patient to describe his/her current understanding of the issue, to help you understand the patient’s level of knowledge and emotional state

• Gives you the opportunity to determine why the patient is at the appointment and sets the basis for any further agenda

• Some sample questions to open your conversation include:

– “Anything else?”

– “To make sure we are on the same page, can you tell me what your understanding of your disease is?”

– “What have your other doctors been telling you about your illness since the last time we spoke?”

  1. Tell them additional needed information in a way that incorporates their perspective

• Tell the patient in straightforward language what you need to communicate - the bad news or treatment options

– Do not give a long lecture or huge amounts of detail.

– Information should be provided in short, digestible chunks.

– A rule of thumb is to give no more than 3 pieces of information at a time.

– Use 9th grade English in communicating. Avoid medical jargon.

Elicit from participants common jargon used by doctors.

How would you rephrase so your patients with limited health literacy can understand?

  1. Ask what they understand and feel about the information given

• Check if the patient understood what you just said.

– Did s/he get the facts straight?

– Is his/her understanding appropriate? Did s/he hear what was said?

– Consider asking the patient to restate what was said in his/her own words.

– “Who are you going to tell about this visit when you get home?”

– “When your daughter calls you about today’s visit, what are you going to tell her?”

– “To make sure I did a good job of explaining to you, can you tell me what you are going to say?”

Activity 3

  • Have the participants break into groups of 2 for role-play, one person acting as the physician, and the other as the patient.
  • They can use any of their own clinical scenarios or ones mentioned in the guide.
  • Assess participants for the skill they choose to practice, like one or more of the following:
  • Ask-Tell-Ask
  • Use of open-ended questions
  • Avoidance of medical jargon
  • After the role-play session, elicit participants’ feedback on what they did well and what they could improve
  • Give specific feedback on aspects done well, and aspects that could be improved.
  • Allow for an opportunity to practice again, if time permits.
  • Then, have the participants change roles, so as to give the other person a chance to be the physician.
  1. Conclusion

Revisit the objectives, positives and challenges faced by the trainees during the session.

  • You don’t have to use every skill with every patient or encounter.
  • Being aware of phrases you can use or skills you can practice in your conversations can be helpful when faced with a challenging situation.
  • Deliberate practice of these skills is crucial in becoming competent (apparently, minimum of 10 years or 10,000 hours to become an expert).

Additional Reading Resources:

  • The National Institute of Aging (NIA) Clinician’s Handbook “Talking With Your Older Patient”
  • Key communication skills and how to acquire them. Maguire P, Pitceathly C. BMJ 2002; 325:697–700.

Case for Activity 2

Case (Mr. Eric Bach)

You are a 68 yo man who presents for back pain for the last 2-3 days (as a result of some heavy lifting at home last weekend). You do not have a PCP, first visit seeing Dr. Angel.

Physician Case (Dr. Angel)

You are seeing Mr. Bach, a 68 yo man who is complaining of back pain that started 2-3 days ago. First visit with you, he does not have a PCP.

Case for Activity 2

Case (Ms. Claudia Sadden)

You are a 75 yo woman who presents for follow up visit with your PCP Dr. Good, for management of Hypertension and Diabetes. And you are also feeling sad since after the death of your pet dog Ronnie last month from bone cancer.

Physician Case (Dr. Good) :

You are seeing Ms. Sadden, your 75 yo patient with HTN and DM. She is here for routine 3-month follow-up of her chronic medical problems.

Case for Activity 3

Case (Mr. Eric Bach)

You are a 68 yo man who presents for back pain for the last 2-3 days (as a result of some heavy lifting of boxes at home last weekend when you were rearranging furniture to tidy up the place), 7-8/10 pain intensity, past history of similar back pain exacerbations. No other major medical problems, do not have a PCP, first visit seeing Dr. Angel. You have gained weight over the years, from poor dietary choices, and not exercising much. You took 1 or 2 Tylenol tablets yesterday, helped a little bit. You wonder if Aleve might better for your pain, but you have heard that Aleve is dangerous because it can cause “bleeding”.

You live alone, served in the army for a few years in the kitchen, schooling till 5th grade. Married twice, divorced both times, have 4 children who are all living in the area.

Physician Case (Dr. Angel)

You are seeing Mr. Bach, a 68 yo man who is complaining of back pain that started 2-3 days ago. First visit with you, he does not have a PCP, and has not seen a doctor in several years.

Case for Activity 3

Case (Ms. Claudia Sadden)

You are a 75 yo woman who presents for follow up visit with your PCP, Dr. Good. You have Hypertension and Diabetes and take Lisinopril 10 mg daily, Amlodipine 5 mg daily and Metformin 1000 gm twice daily. And you are also feeling sad since after the death of your pet dog Ronnie last month from bone cancer. Because of this, you have not been taking your medicines regularly, and also eating more and not going for walks as much as before. Also, you have not been checking your blood sugar once every day like you used to. When the nurse checked your sugar in the clinic today, it was 349. It has never been so high. You are very anxious.

You live alone and are very independent, live in a 10th floor apt in an elevator bldg.

Physician Case (Dr. Good) :

You are seeing Ms. Sadden, your 75 yo patient with HTN and DM who takes Lisinopril 10 mg daily, Amlodipine 5 mg daily and Metformin 1000 gm twice daily. She is here for routine 3-month follow-up of her chronic medical problems.

1