Enhancing Physician – Patient Communication

Here it is3 x4Find x.

• Information to be communicated.• Method of communication.• Speaking• Writing / Drawing• Ability to be interpreted by the recipient.• Comprehension (and retention) of theinformation.• Issue specific concerns.

• Great model for physician – patientcommunication• Tons of data• Recommendations of specific information to becovered• Talks typically include significant medicalinformation• Physicians don’t do such a great job (as we willsee…)

• It takes too long• It’s uncomfortable for the patient• It’s uncomfortable for me• I don’t think they are going to die soon• The Consultant / Resident / Student / Nurse /EMT had the discussion already...• I don’t want the patient to give up hope• They don’t want to stop all of their treatments

• Per the attending physician questionnaireanswers:• Does the patient have a terminal illness?• Would you be surprised if this patient died or wasadmitted into an ICU within the next year?

• Among seriously ill admissions:No discussionDiscussion

• Any patient at risk for requiring it• Begin with discussion of prognosis, generalvalues, goals and preferences for EOL care.• Discuss CPR as an intervention including thelikelihood of needing CPR, risks, benefits andpossible outcomes.• Make a recommendation for CPR consistentwith the patient’s prognosis and preferences.

• Only 1/19 code status discussions includedprognosis• Patient Preference discussions were brief andexplored the use of life sustaining interventionsrather than life goals• When quality was discussed, the quality of lifeor function that would be acceptable was notdiscussed

• Only 2/19 discussions included the word“death” or “die”• Jargon such as resuscitation, CPR andcompressions were used, but not defined• All estimations of the likelihood of requiringCPR were framed as the physician’sreassurance that the patient would not requireit.

• Risks, benefits and outcomes were expressed asgetting better versus not being able to get offlife support. The survivability of a code wasnot discussed.• Patients used euphemisms such as “vegetable”and “invalid” but these terms were notexplored to determine what the patient meantby them.

• No physician at any time made arecommendation to the patient.

“Sometimes we do a few things to see if we canget your heart restarted again and kind of reviveyou and sometimes that means you end up in theintensive care unit on machines for a few days,but some people do get better from that”Part of a discussion between an attending physician anda 72 year old woman with a CNS lymphoma who is beingadmitted for chemotherapy.

• Dedicate time• Define terms• Discuss efficacy and outcomes• Determine what the patient really wants• Document in detail• Define the care plan in light of the goals

• Speech ability orlanguage articulation• Foreign languagespoken• Dysphonia• Time constraints(patient or physician)• Inability to meet faceto-face• Illness• Altered mental state• Medication effects• CVA• Psychological oremotional distress• Gender differences• Racial or culturaldifferences• Others (Dress, setting,etc..)Travaline, JM, Ruchinskas R, D’Alonzo, GE.Patient-Physician Communication: Why and How.JAOA. 2005. 105(1). 13-18.

• Setting and Listening Skills• Patient Perception• Invitation• Knowledge• Explore emotions and Empathize• Strategy and SummaryMueller, P. (2002). Breaking Bad News to Patients:The SPIKES approach can make this difficult task easier.Postgraduate Medicine , 112(3), 15-16, 18.

• Find an appropriate place• Private• Comfortable• Practitioner seated at or below eye level• Listening Skills• Put the phone on vibrate and set up time• Focus not just on the information to present, butprepare to actively listen to the response Listen / Rephrase / Repeat

• What does the patient know about theircondition?• What is the patient’s general attitude about thecare being given?• Are there any patient specific circumstancesthat need to be addressed?• Patient is uncomfortable.• Patient wants spouse or children present.• Set the tone.

• Before giving the information, ask if the patientwants it.• If the patient doesn’t want it, to whom shouldthe information be presented?• Culturally may be a spouse or child• The dispensing of information is related todecision making.• REASSURE AND RESPECT THE PATIENT’SDECISION.

• Tell what you know and explain it in thesimplest possible terms• Be direct• Be clear – not soft Dead, death, dying• Go slow• Use comparisons if needed to explain an abstractconcept.• Keep in mind the language capacity of theAVERAGE American is a reading level of 8 th grade.

• Encourage questions – Actively listen• Offer emotional support• Be clear in what you CAN do and what youCAN’T do• Be non-verbal

• Offer choices or outline a plan• Focus on helping the patient to establishrealistic goals• “I’m going to beat this!”• Be prepared for any reaction – even none• D / A / B / G / A• Summarize your next steps with the patient

• Empathy• Courtesy / Friendliness• Attentiveness during history taking• Support / Reassurance / Positivereinforcement regarding patient actions• Encouragement of Patient questions• Laughter as tension releaseBeck RS, Daughtridge R and Sloane PD.Physician-Patient Communication in the Primary Care Office: ASystematic Review.Journal of the American Board of Family Practice. 2002.15 (1): 25-38.

• Listening• Giving health education• Clarifying statements• Summarizing patient statements• Talking at patient’s level• Addressing patient’s daily lives, problems,social relations and emotionsBeck RS, Daughtridge R and Sloane PD.Physician-Patient Communication in the Primary Care Office: ASystematic Review.Journal of the American Board of Family Practice. 2002.15 (1): 25-38.

• Head nodding• Leaning forward• More direct body orientation• Uncrossed arms and legs• Less mutual gazeBeck RS, Daughtridge R and Sloane PD.Physician-Patient Communication in the Primary Care Office: ASystematic Review.Journal of the American Board of Family Practice. 2002.15 (1): 25-38.

• Excessive focus on medical questions• Showing tension, anger or nervousness• Allowing interruptions• Withholding information or explanations• Leaning back / Angled away from patient• Frequent touching• Unduly dominant approach• Directive behaviorBeck RS, Daughtridge R and Sloane PD.Physician-Patient Communication in the Primary Care Office: ASystematic Review.Journal of the American Board of Family Practice. 2002.15 (1): 25-38.

• Communication skills are now beingemphasized in all levels of medical educationand training• Continued certification will likely includeongoing demonstration and improvement ofcommunication skillsLevinson W, Lesser CS, Epstein RM.Developing Physician Communication Skills forPatient Centered Care.Health Affairs. 2010. 29(7). 1310-1318.

• Utilize a protocol for communication – SPIKES• Pay attention to verbal and non-verbalbehavior• Commit time and effort into communication• Be truthful, clear and patient• Empathize• Support your patients in planning, decisionmaking and execution of the plan