12.Communication 07
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Transcript of 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.
Essential Element of Medical Communication (cont)
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.
Essential Element of Medical Communication (cont)
3. Gather Information (cont)
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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
Essential Element of Medical Communication (cont)
3. Gather Information (cont)
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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
Essential Element of Medical Communication (cont)
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5. Share Information Use language the patient can understand
Check for understanding
Encourage questions
Essential Element of Medical Communication (cont)
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6. Reach Agreement on Problems and Plan
Essential Element of Medical Communication (cont)
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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
Essential Element of Medical Communication (cont)
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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
http://www.mdanderson.org/departments/neuro/display.cfm?id=1AAFE6C8-833E-11D4-AEC800508BDCCE3A&method=displayFull&pn=0337644E-832A-11D4-AEC800508BDCCE3Ahttp://www.mdanderson.org/departments/neuro/display.cfm?id=1AAFE958-833E-11D4-AEC800508BDCCE3A&method=displayFull&pn=0337644E-832A-11D4-AEC800508BDCCE3Ahttp://www.mdanderson.org/departments/neuro/display.cfm?id=1AAFE958-833E-11D4-AEC800508BDCCE3A&method=displayFull&pn=0337644E-832A-11D4-AEC800508BDCCE3Ahttp://www.mdanderson.org/departments/neuro/display.cfm?id=1AAFEC3C-833E-11D4-AEC800508BDCCE3A&method=displayFull&pn=0337644E-832A-11D4-AEC800508BDCCE3Ahttp://www.mdanderson.org/departments/neuro/display.cfm?id=1AAFEC3C-833E-11D4-AEC800508BDCCE3A&method=displayFull&pn=0337644E-832A-11D4-AEC800508BDCCE3Ahttp://www.mdanderson.org/departments/neuro/display.cfm?id=1AAFEE55-833E-11D4-AEC800508BDCCE3A&method=displayFull&pn=0337644E-832A-11D4-AEC800508BDCCE3Ahttp://www.mdanderson.org/departments/neuro/display.cfm?id=1AAFEE55-833E-11D4-AEC800508BDCCE3A&method=displayFull&pn=0337644E-832A-11D4-AEC800508BDCCE3Ahttp://www.mdanderson.org/departments/neuro/display.cfm?id=1AAFF0B5-833E-11D4-AEC800508BDCCE3A&method=displayFull&pn=0337644E-832A-11D4-AEC800508BDCCE3Ahttp://www.mdanderson.org/departments/neuro/display.cfm?id=1AAFF0B5-833E-11D4-AEC800508BDCCE3A&method=displayFull&pn=0337644E-832A-11D4-AEC800508BDCCE3Ahttp://www.mdanderson.org/departments/neuro/display.cfm?id=1AAFF64E-833E-11D4-AEC800508BDCCE3A&method=displayFull&pn=0337644E-832A-11D4-AEC800508BDCCE3Ahttp://www.mdanderson.org/departments/neuro/display.cfm?id=1AAFF64E-833E-11D4-AEC800508BDCCE3A&method=displayFull&pn=0337644E-832A-11D4-AEC800508BDCCE3Ahttp://www.mdanderson.org/departments/neuro/display.cfm?id=1AAFF64E-833E-11D4-AEC800508BDCCE3A&method=displayFull&pn=0337644E-832A-11D4-AEC800508BDCCE3Ahttp://www.mdanderson.org/departments/neuro/display.cfm?id=1AAFF64E-833E-11D4-AEC800508BDCCE3A&method=displayFull&pn=0337644E-832A-11D4-AEC800508BDCCE3Ahttp://www.mdanderson.org/departments/neuro/display.cfm?id=1AAFF0B5-833E-11D4-AEC800508BDCCE3A&method=displayFull&pn=0337644E-832A-11D4-AEC800508BDCCE3Ahttp://www.mdanderson.org/departments/neuro/display.cfm?id=1AAFF0B5-833E-11D4-AEC800508BDCCE3A&method=displayFull&pn=0337644E-832A-11D4-AEC800508BDCCE3Ahttp://www.mdanderson.org/departments/neuro/display.cfm?id=1AAFEE55-833E-11D4-AEC800508BDCCE3A&method=displayFull&pn=0337644E-832A-11D4-AEC800508BDCCE3Ahttp://www.mdanderson.org/departments/neuro/display.cfm?id=1AAFEE55-833E-11D4-AEC800508BDCCE3A&method=displayFull&pn=0337644E-832A-11D4-AEC800508BDCCE3Ahttp://www.mdanderson.org/departments/neuro/display.cfm?id=1AAFEC3C-833E-11D4-AEC800508BDCCE3A&method=displayFull&pn=0337644E-832A-11D4-AEC800508BDCCE3Ahttp://www.mdanderson.org/departments/neuro/display.cfm?id=1AAFEC3C-833E-11D4-AEC800508BDCCE3A&method=displayFull&pn=0337644E-832A-11D4-AEC800508BDCCE3Ahttp://www.mdanderson.org/departments/neuro/display.cfm?id=1AAFE958-833E-11D4-AEC800508BDCCE3A&method=displayFull&pn=0337644E-832A-11D4-AEC800508BDCCE3Ahttp://www.mdanderson.org/departments/neuro/display.cfm?id=1AAFE958-833E-11D4-AEC800508BDCCE3A&method=displayFull&pn=0337644E-832A-11D4-AEC800508BDCCE3Ahttp://www.mdanderson.org/departments/neuro/display.cfm?id=1AAFE6C8-833E-11D4-AEC800508BDCCE3A&method=displayFull&pn=0337644E-832A-11D4-AEC800508BDCCE3A -
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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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