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Enhancing Relationship-Centered Communication for

the HIV ProviderElizabeth Imbert, MD MPH

Assistant ProfessorDivision of HIV, ID, and Global Medicine

Zuckerberg San Francisco GeneralUCSF

I have no disclosures

Objectives

• Identify 3 steps of Relationship-Centered Communication skill set• Develop an action plan to supports applying these skills in a clinical

context

Communication: The most common procedure

How many patient interactions in a health care provider’s career?• > 200,000• Less training, practice, and feedback than

other less common procedures•Computers add complexity

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1Relationship-Centered Care leads to

better outcomes…

Better Outcomes for Patients

• Diabetes• Pain management• Adherence to

medications• Satisfaction with care

experiencesSafran et al, J Fam Pract 1998; Stewart et al, J Fam Pract 2000; Levinson et al, Health Affairs 2010; Dwamena et al, Cochrane

Database Syst Rev 2012; Hojat et al, Acad Med 2013; Kennedy et al, Pat Experience J 2014

Better Outcomes for Clinicians and Teams• Engagement• Satisfaction• Workload stress• Medical

malpractice

Levinson et al, JAMA 1997; Krasner et al, JAMA 2009

Overview of Relationship-Centered Interviewing skills

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Step 1: Set the Stage

Skills:• Build rapport quickly• Elicit all of the other's agenda items• Negotiate the agenda• Introduce the computer

Set the Stage: Greeting

• Welcome/greet the patient and

others

• Integrate interpreter

• Acknowledge delay, if any

• Identify patient and others by name

• Introduce yourself to everyone in the

room

• Explain your specific role

Set the stage: Attend to comfort & minimize communication barriers

• Ensure readiness and privacy• Minimize barriers to communication (sit down)• Adapt language, pace, posture in relation to other

• Ensure comfort• Make a social comment or ask a nonmedical

question• State the time for the encounter

Set the stage: Elicit ALL agenda items

• Outpatients average 3-4

concerns per visit• More efficient

• 35 vs. 15% doorknob questions

• Main concern often not

offered first

Marvel et al, JAMA 1999; Heritage et al, JGIM 2007

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Set the stage: Elicit all agenda items

• “First, let me write down a list of

everything you want to talk about

today.”

• “What else?” until all items

exhausted – before addressing first

item

• Summarize the entire list

Set the stage: Negotiate the agenda

1. Establish other's priorities: “Of those 4, which is most important to you today?”

2. State your concerns: “I’m concerned about your asthma.”

3. Offer a plan: “Can we start with your breathing, then your headache, then your blood pressure medications? I’ll need a few days to help you with the form.”

Step 2: Elicit & Respond to the Other’s Perspective

Skills:• Explore the other's function, ideas,

fears, and expectations• Demonstrate empathy verbally and

non-verbally• Transition to data-centered portion

of encounter

Overview of Relationship-Centered Interviewing Skills

SetStage

SetAgenda

Relationship-CenteredSkills

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Pandora’s Box

• How quickly do you think health care providers interrupt patients?

• How long will patients speak if given the opportunity?

The Other’s Perspective

• Begin with an open-ended request / question

• “Tell me all about …”

• Listen attentively and silently

• Can use neutral utterances and nonverbal

encouragement

• Resist the urge to jump to questions

Tools for active listening

• Pauses

• Echoing

• Requests for more information

• Reflections and summaries

Skills practice

v Work in dyads.

v You will be in two different roles for 2 minutes each.1. Storyteller describes a challenge in a working

relationship – with a patient, colleague, supervisor, etc.

2. Interviewer uses pauses, echoing, requests for more information, and reflections/summaries (NOT close-ended questions, advice, or his/her own stories).

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Debrief

v For the storyteller roles: What was it like to tell your story and experience reflective listening?

v For the interviewer roles: How was it to listen reflectively?

Need more information? Elicit the other’s function, ideas, fears, and expectations

1. Function“How has this affected your comfort at work?”

2. Ideas“What are your ideas about what might becausing this?”

3. Fears“What worries you about this?”

4. Expectations“How can I best help you today?”

Weston, Brown, & Stewart: Can Fam Physician. Jan 1989

Explore and Name the Patient’s Emotion

Patients almost always have emotions accompanying their

symptoms/illnesses

•Recognize expressed emotion•Nonverbal emotional expression•Emotional cues•Statements of feeling

•Elicit Emotion• Ask explicitly• Hypothesize about the patient’s

emotion

Symptom

Personal

Emotional

Elicit & respond: If not explicit, seek out emotion--

• “How has this been for you,emotionally?”

• “How are you doing with all this?”

• Read the emotion on the other's face• “You seem frustrated.”

Fortin, Dwamena, Frankel, Smith 2012.

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Convey empathy nonverbally

• Pause• Touch• Facial expression• Tone of voice• Space

Ambady et al, Surgery 2002; Riess et al, JGIM 2014

Express empathy: Make at least one empathic statement

PEARLS:• Partnership• Emotion• Apology• Respect• Legitimization• Support

PEARLS© statements

Partnership: Let’s work together on this.

Emotion: I imagine how upsetting this is for you.Apology: I’m sorry to hear how difficult this is.

Respect: I give you a lot of credit for getting through this as you have.Legitimization: Most people in your position would feel this same way.Support: I’m going to stick with you through this.

Empathy enhances efficiency

Madeempathicstatements

Missed an opportunity for an empathic statement

Internists 17.5 min visits 20 min visits

Surgeons 12.5 min visits 14 min visitsLevinson et al, JAM A 2000; Hojat et al, Acad M ed 2011

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Be aware of your own reactionsSelf-awareness• How am I feeling? • Does a power differential exist?

Non-judgmental attitude• Separate the behavior from the person• Speak as an equal partner• Focus on strengths

Transition to data-centered part of encounter• Check accuracy with a brief summary• Indicate that both content and style of

inquiry will change if patient is ready• Continue with the data-centered portion of

the encounter: remainder of history, exam, etc.

Continue connecting and expressing compassion!

Step 3: Negotiate a shared plan

Skills• Share information

• Assess understanding

• Summarize & clarify

• Close the encounter

Overview of relationship-centered interviewing skills

Clinician-CenteredSkills

PhysicalExam

Relationship-centered

Relationship-centered

Relationship-centered

Relationship-centered

EndEducateCounselPlan

SetStage

SetAgenda

Relationship-CenteredSkills

Beg inning

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Share information

• Orient and ask permission to begin discussion

• Frame the discussion according to the patient’s perspective – ideally already elicited

• Deliver in small, jargon-free amounts

• Allow space for emotion & questions

A Typical Download

• Continues with the clinician speaking at length about the diagnosis and treatment plan, and what the next steps for thepatient will be, including medication changes, lifestyle recommendations, procedural details, consultations, important things for the patient to know about, maybe ending withasking the patient for any questions …

ART Loops

ART

ART

ART

• Difference between dialogue and monologue

• Can be used to elicit:• Patient/family

preferences, goals• Barriers

• Ensures simplicity and maximizes adherence

Assess Understanding: ARTS

Ask for other's understanding

Reflect/ respond with asummary or empathic statement

Tell/teach

Seek alignment, solutions

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Example

ASK: What have you heard about asthma?Patient: Oh no. My sister had asthma as a kid. It was awful – she had to go to the ER all the time with my parents toget treatment.REFLECT: I’m sorry to hear your sister had such severe asthma.TEACH: I don’t think your condition is nearly as serious as hers. Some people get asthma reactions when they have a virus or allergy, and quickly improve with an inhaler.ASK: What is your experience with inhalers? …

Negotiate a shared plan: Develop achievable action plans

• Tailored to patient's goals,

resources, and

preferences

• Specific

• Achievable

Summarize and clarify with teach back

• Teach back leads to

improved outcomes

• Promotes adherence

• Allows for collaborative

planningSchillinger et al, 2003; Schenker et al, 2011

Summarize and clarify: Teach back, using ARTv Ask the patient to summarize

“We’ve covered a lot: can you tell me in your own words what we’ve decided on?”

“When you speak with your family member / friend,what will you tell them we discussed?”

v Respond/Reflectv Teach additional points, as needed

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Close the encounter

• Further clarify future plans, asnecessary• What you / the patient will do• What the time of the next communication will be

• Elicit final questions• “What further questions do you have?”

• Acknowledge and support• “It is a pleasure to work with you.”• “We’ll be here if you need help.”

Summary: Relationship-Centered CommunicationDemo and skills practice

q Step 1: q Set the stageq Elicit items & negotiate agendaq Introduce the computer

q Step 2:q Open the conversationq Elicit perspectives (FIFE)q Respond with empathy (PEARLS)

q Step 3:q Share information & plansq Assess understanding with ARTS:

q Ask with open-ended inquiry, Reflect,

Tell/teach, Seek alignment and solutionsq Summarize and clarify: ask for teach backq Close the encounter