12.Communication 07

8/12/2019 12.Communication 07

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MEDICALCOMMUNICATION SKILL

LECTURETheresia L. Toruan


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Think back for a minute on your own lifeexperiences

Recall from your own interaction with yourdoctor or dentist

The quality of the communication thatinvolved


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Was it clear?

Was it sympathetic?

Were you left with the impression that youwere told as much as you wanted toknow?

Were you left with the impression thatyour doctor was a good listener?


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A Changing Paradigm

Paternalistic

Reductionist

Holistic and

Collaborative

pproach

ommunication

skills of the

physician are

critical


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Paternalistic approach

To deciding what should be done for a patient:

The physician knew best Patient accepted the recommendation

Patient without question


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SHARED DECISION MAKING(holistic and collaborative

approach)

Advising to educate his or herself

To ask question

PHYSICIAN-PATIENT SATISFACTIONREDUCTION IN MEDICAL RISK


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Communication Age

able to communicateinformation

faster more clearly

more widely


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The basis for patient-physician alliance

Communication establishes the collaborativenature of that alliance

shared decision-making

partnering


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Medical communication.. own life experience!

Clear?

Sympathetic?

Left in the impression not told as much as wanted to know?

Left with the impression the doctor was a good listener?

Our experience with health and illness are significant to

our sense of health.


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The benefits of good communication:

Good communication:

builds trust between patient and doctor;

may help the patient disclose information; enhances patient satisfaction; involves the patient more fully in health decision

making; helps the patient make better health decisions; leads to more realistic patient expectations; produces more effective practice; and

reduces the risk of errors and mishaps.


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Toronto Consensus Statement(1980): talking about

the importance of Medical communication Skill

and

Kalamazoo Consensus Treatment(1999): talking about

the Essential Element of the Medical Communication based

on the task approach


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Essential element of Medical

Communication

1. Build a relationship2. Open the discussion3. Gather Information

4. Understand the patients perspective5. Share information6. Reach agreement on problems and plan7. Provide closure


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Essential Element of Medical Communication (cont..)

1. Build a Relationship

Fundamental communication task

Strong

Therapeutic Effective relationship (idea, feelings, and

values of both)

Also relevant for work with the patient, familyand other support system

Is an ongoing taskwithin and across


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Essential Element of Medical Communication (cont..)

Mnemonic P E A R L S : P..partnership, acknowledges that the physician and the patient

are in this together

E..empathy, expresses understanding to the patient

A..apology, acknowledges that the phycisian is sorry the patienthad to wait, that a laboratory test had to be repeated, etc

R..respect, acknowledges the patients suffering, difficulties, etc

L..legitimization, acknowledges that many patient are angry,

frustrated, depressed, etc S..support, acknowledges that the physician will not abandon

the patient.

1. Build a Relationship. (cont)


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Essential Element of Medical Communication(cont)

2. Open the discussion

Physicians first greeting.

Physician show personal concern by offering

a handshake and warm smile. Put the patient at ease in what could

otherwise to be unfamiliar, if not frightening

environment.


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3. Gather Information Shifting from a physician-centered to patient-centered interview

style

Physician interrupt patients an average of 18 seconds after thepatient begins to speak.

Patient rarely continued to express all their true concern oncethey were interrupt

No more than 150 seconds was needed to express all their

concern at the beginning or the interview Two words . What else?

Essential Element of Medical Communication (cont)


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Five Communication Pattern :

Narrowly biomedical

Expanded biomedical Biopsychosocial

Psychosocial

Consumerist.


3. Gather Information (cont)


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Five Communication Pattern(cont)Example :

Physician : What bring you here?

Patient : I have headache Physician : Where are the headache? How long do

they does? What do you do to relieve them?

This interview follows a physician centered and biomedicalmodel pattern.

Contrast the previous interview with the following interview.




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Five Communication Pattern(cont)

Example :Physician : What brings you here today?

Patient : I have headache.Physician : What else?Patient : Well, I have problems on sleeping.Physician : What else?Patient : I am very worried about my son. He is

using drugs.

This interview follows a patient-centered andbiopsychosocialpattern




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4. Understand the Patients Perspective

Explore contextual factors (e.g., family, culture, gender,

age, socioeconomic status, spiritually) Explore beliefs, concern, and expectation about health and

illness

Acknowledge and respond to to the patients ideas,

feeling, and values



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5. Share Information Use language the patient can understand

Check for understanding

Encourage questions



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6. Reach Agreement on Problems and Plan



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7. Provide Closure

Ask whether the patient has other issues or

concern

Summarize and affirm agreement with the plan

of action

Discuss follow up



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Special Medical Communication

End-of-life communication

Bad News

Old Patient Family caregivers

S i l M di l C i ti


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End-of-life communication

Reflection:

And I came to understand that this was medicine,

and this was so much greater than my nave ideas

of complete cures and miraculous recoveries, whichare too few and far between; that the true practiceof medicine is not the miraculous cure of a diseasebut the total care of a person.

Special Medical Communication (continue)

S i l M di l C i ti


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Bad News

Mnemonic S P I K E S protocol for breaking bad news.

S..etting and listening skills

P..erception by patient of condition and seriousness

I..nvitation from patient to give information

K..nowledge - giving medical facts

E..xplore emotions and empathize as patientresponds

S..trategy and Summary

Special Medical Communication (cont)

S i l M di l C i ti
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Old Patient

Working Memory Capacity Diminish

Hearing and Vision lost Reflective listening

Create Hope

Special Medical Communication (cont)

Special Medical Communication ( )


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Family Caregivers

Understand that illnes and disability are afamily affair. Let the patient know

Be sensitive about place talking to caregiversabout difficulty subjects. Not appropriate inwaiting room and corridors.

Special Medical Communication(cont)


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EMPHATY

Of all the element involved in effectivecommunication: the most powerful

1880, psychologist Theodore Lipps: einfuhlung

(in-feeling) To describe: emotional appreciation of

anothers feeling

Being a psychiatric or mental health expert is not necessaryfor usingemphatetic communication

The only requirement is an awarenessof opportunities for emphaty asthey arise during the interview with the patient


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In emphaty, we borrow anothersfeelings to observe, feel, and understandthem - - but to take them onto ourselves

By being a participant-observer, we cameto understand how the other person feels

EMPHATY versus SYMPHATY?


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Empathy

Key skill used to built doctor patient-relationship

Empathic processes affect how the physician (observer)

thinks, feels (intrapersonal outcomes), and behaves

(interpersonal outcomes) with the patient (target)

The process of understanding a persons subjective

experience

Balance curiosity to leading to a deeper understanding of

another human being

The capacity to understand another person experience fromwithin that person s frame of reference

The ability to put oneself in anothers shoes


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Empathy (cont)

Begins to look something like:

Touch the patient on the arm

Look them in the eye

If the patient stop talking, repeat the last word that they said

to show you are listening and interested.

Doing so without also developing a genuine interestin the

resulting connection can lead to an empty charade

Effectively teaching useful approaches to physician-

patient relationship


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Empathy (continue)

Deepened understanding of Empathy

For one year now, I have been trying to come to terms

with the notion of sacred, esteemed, professional doctor-

patient relationship. Somehow, I had gotten the idea in my

head that this relationship should be somehow devoid ofemotions. It took a women like nurse Cindo and a patient

like Mr. Lanang to help me to realize that it might actually be

okay, normal, and human to cry and to express emotions

about a wonderful dying patient


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Active Listening

The most important skill of medical communicationto learn.

Involves two way tramsmission of verbal and non-

verbal behaviour between doctor and patient. The aim is to encourage the patient to continue theiropening statement as far as possible withoutinterruption.

Closely linked to the doctors capacity to recognize

emotional factors contributing to illness and distress.


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Active Listening(cont)

Mnemonic S O L E R, positive non-verbals that canbe used to indicatephysician are listening supportively.

Ssitting square on to the patient with an

Oopen position

L leaning slightly forward with

Eeye contact in a

R relaxed posture


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Collaboration in Health Care

Involves coordination of individual actions in Cooperating in planning

Working together

Sharing of goal, planning, problem solving, decisionmaking and responsibility

Can happened between two people who

represent the same or different disciplines.


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Collaboration in Health Care(cont)

Nurse-Physician Collaboration

Nurse Practitioner-Physician Collaboration

Social Worker-Physician Collaboration

Pharmacist-Physician Collaboration

Physician-Physician Collaboration


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The Impact of Poor Communication

Poor communication: decreases confidence and trust in medical care;

deters the patient from revealing important information;

causes significant patient distress;

leads to the patient not seeking further care;

leads to misunderstandings;

leads to the misinterpretation of medical advice;

underlies most patient complaints; and

predicts negligence claims.

These difficulties may lead to poor or sub-optimal outcomes for thepatient.


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Doctor-related Obstacles

The doctor may be:

inadequately trained in communication skills;

lacking in sensitivity or empathy;

unwilling to recognise patient autonomy; unaware of problems arising from differences inlanguage and culture;

affected by time pressures; or distracted by external

or personal factors.


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Patient-related obstacles

The patient may be: affected by the condition, illness or medication; anxious, embarrassed or in denial about the medical condition; inexperienced in identifying and describing symptoms; intimidated by health care settings;

overawed by the doctors perceived status; disadvantaged by differences in language and culture; confused by the use of medical jargon; reluctant to ask questions; or concerned about time pressures.

All of these factors may impede the patients capacity to provide, takein and retain information.


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COMMUNICATION

Its a series of learned skill

Experience is a poor teacher: it needsobservationplus well intentioned,constructive, detailedanddescriptive feedbackplus rehearsel

to effect change


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12.Communication 07

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