Building relationships and managing expectations€¦ · Building relationships and managing expectations Dr Catherine Hood. The communication challenge •Doctors perform 200,000

Building relationships and managing expectations

Dr Catherine Hood

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

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

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

Two-agenda model for person-centred communication

• Signs

• Symptoms

• Investigations

Differential

diagnosis

Stewart et al. Patient-Centred Medicine. Radcliffe, 1995

HCP agenda Patient’s agenda

Personal

understanding

◦ Feelings

◦ Ideas

◦ Function

◦ Expectations

PATIENT

Disease Illness

Integrated Understanding

Management Plan

Two-agenda model for person-centred communication

• Signs

• Symptoms

• Investigations

◦ Feelings

◦ Ideas

◦ Function

◦ Expectations

PATIENT

Disease Illness

Stewart et al. Patient-Centred Medicine. Radcliffe, 1995

Differential

diagnosis

HCP agenda Patient’s agenda

Personal

understanding

Integrated Understanding

Management Plan

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








How do you engage different patient types?

Challenge 1

Interactive exercise 1

Discuss the patient profiles 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

Self-manager

• Tend to have the most positive outlook on life

• Psoriasis has least impact on quality of life

• Not as likely to be current users of prescription medicine; would avoid using treatments unless necessary

• Least receptive to new treatments

• Refer to psoriasis information least frequently

• 72% have mild psoriasis

Why me?

• Psoriasis not as severe as ‘Help me’ group; however, not coping that well with psoriasis

• 50% use prescription medicine; 33% use non-prescription medicine

• Not as satisfied with topicals; would try to avoid prescription medicine unless necessary

• Least trusting of their HCPs

• Least adherent segment (41%)

• 53% have moderate psoriasis; 35% mild

Help me• Tend to have the most negative outlook

• Highest percentage of body affected by psoriasis

• Psoriasis has highest impact on quality of life

• Tend not to have a good relationship with their HCP

• Most receptive to new treatments

• Refer to psoriasis information the most frequently

• 57% have moderate psoriasis; 32% severe

Actively engaged

• 40% use prescription medicine and 40% use non-prescription medicine

• Have the most positive relationship with their HCP

• Tend to trust their HCP the most

• Tend to have a good level of satisfaction of topicals

• The most adherent segment (54%)


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

Communication approaches

• Based on:• The characteristics associated with each patient profile

• The different ways of adapting communication style during a consultation

• How can we tailor our approach to each profile type?

The Self-Manager

• Let them express their ideas

• Develop treatment targets and goals

• Explore any hidden worries

• Learn from them

• Understand that they have good coping skills

40%

The ‘Why Me?’ patient

• Impart more knowledge

• Show empathy

• Listen to what they want

• Express feelings

• Build support

28%

◦ Prioritise

◦ Bring to acceptance

◦ Not focus on prognosis

The ‘Help Me’ patient

• Support them • Information• Disease / Treatment

• Hand-holding

• Develop rapport

• Realistic goals

• Make sure they have not given up

16%

The Actively Engaged patient

• Understand that they may know a lot about their disease

• Understand that they may challenge our authority

16%

Gathering information

• The appropriate use of questions

• Active listening

• Picking up cues into the patient agenda

• Summary and checking


1. The appropriate use of questions

• Open, closed, focused


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


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)


4. Summary and checking• Summarise to check own understanding

of what has been heard

• Clarify with the patient

How to gather information?

Challenge 2

Interactive exercise 25 minutes per role play

• 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

Giving feedback

• Confidentiality

• What was done well? • Ask the individual then ask the group

• What could have been done better?• Ask the individual then ask the group

• Was the outcome good for the doctor?

• Was the outcome good for the patient?

• If not, why not?

Gathering information: summary

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








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

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

How do you know how much information to give?

Challenge 3

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?

• Feedback to group

Self-manager

• Tend to have the most positive outlook on life

• Psoriasis has least impact on quality of life

• Not as likely to be current users of prescription medicine; would avoid using treatments unless necessary

• Least receptive to new treatments

• Refer to psoriasis information least frequently

• 72% have mild psoriasis

Why me?

• Psoriasis not as severe as ‘Help me’ group; however, not coping that well with psoriasis

• 50% use prescription medicine; 33% use non-prescription medicine

• Not as satisfied with topicals; would try to avoid prescription medicine unless necessary

• Least trusting of their HCPs

• Least adherent segment (41%)


Help me• Tend to have the most negative outlook

• Highest percentage of body affected by psoriasis

• Psoriasis has highest impact on quality of life

• Tend not to have a good relationship with their HCP

• Most receptive to new treatments

• Refer to psoriasis information the most frequently

• 57% have moderate psoriasis; 32% severe

Actively engaged

• 40% use prescription medicine and 40% use non-prescription medicine

• Have the most positive relationship with their HCP

• Tend to trust their HCP the most

• Tend to have a good level of satisfaction of topicals

• The most adherent segment (54%)


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 signals about how much involvement they would like

• Patient personality type will influence their level of involvement and information needs

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

Tips to improve information retention

• Logical sequence to the information

• Repeat and summarise

• Check understanding

• Diagrams and written materials

How to manage difficult patients

Interactive session

Patient one

Task 1

• Observe the video

• Observe the skills using the tracker if it helps

Patient one

Giving feedback

• Confidentiality

• What was done well? • Ask the individual then ask the group

• What could have been done better?• Ask the individual then ask the group

• Was the outcome good for the doctor?

• Was the outcome good for the patient?

• If not, why not?

Discuss in small groups

• What is their profile?

• How was the first part of the consultation managed?

• Considerations when discussing treatment

• Feedback to the group

Patient one

Managing anxious patients

• Observe non-verbal and verbal cues for anxiety

• Non-verbal – sweating, fidgeting, heavy breathing, poor eye contact, difficulty with concentrating

• Verbal – repeating sentences or words, inability to retain information

• Rapport – building a good rapport is essential but can be a challenge

• Patients need to feel they are taken seriously

• Active listening – explore patients concerns and ideas to try and understand the source of their anxiety

• Health, family, financial concerns

• Generalised or specific

• Associated depression

• Empathy – show empathy with the patients situation

• Shared management – try to involve the patient in decisions about treatment in order to show their concerns have been heard but also to give them control

• Summarise frequently and check understanding

• Reassure frequently and appropriately

Break

Patient two

Patient two






Patient two

Managing angry patients

• Observe verbal and non verbal cues for anger

• Passive aggression vs overt aggression

• Safety first

• Introductions

• Stay calm and polite – distance yourself emotionally, take time out if appropriate. Slow voice and lower vocal tone, keep open body position

• Active listening – explore ideas and concerns using open questions

• Generate a problem list

• Show empathy

• Use ‘I’ phrases not ‘you’ phrases e.g. I can appreciate this is difficult vs you are finding this difficult

• Explore solutions and apologise if appropriate

• Summarise and check frequently

Patient three

Patient three






Patient 3

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

The last word

Adapt your style…

…and if you remember only one thing, remember the first 2 minutes of a consultation are key

Break

Documents

Building relationships and managing expectations€¦ · Building relationships and managing expectations Dr Catherine Hood. The communication challenge •Doctors perform 200,000