Patient CommunicationsPS 5204

Professional Issues – Communications & Referral

“the counseling class...”Dr. Alex Alexander

Why Am I Teaching You?

• Military Medicine

• Naturopathic Degree

• Mental Health Counseling Masters

• Practitioner for 100 years

• Teaching acupuncture students Western Medicine since 2009

• Specialist in communications - Verbal and Nonverbal

What’s Expected?

• Let’s look at the syllabus

• COURSE WEBPAGE: dralexclassblog.wordpress.com

TEXTBOOK

• Hersen, M. & Van Hesselt, V.,(2008). Basic Interviewing: A Practical Guide for Counselors and Clinicians, 1st Edition Reprint. East Sussex: Psychology Press (required)

• Millenson, J. (1995) Mind Matters: Psychological Medicine in Holistic Practice, Seattle: Eastland Press (optional)

Required Text

• Weekly Readings are MANDATORY

• Lab exercises will follow along

• Lab is evolving...

Optional Text

Why Mind Matters Text?

Psychological Medicine in Holistic Practice

Great Personal Healing Story

Textbook for Mind-Body Medicine

Who Cares?

What does Mind-Body Medicine have to do with Acupuncture?

3 essential fluids? jing, qi, blood?

You tell me... how do you choose points? What is this based on? Relevance?

Communication is Everything

PROVE IT.

The Science

Study: Acupuncture Practitioner - Patient Communication in Japan

Published in: 2008 International Journal of General Medicine

AbstractWe evaluated acupuncture practitioner–patient communication using pairs of practitioners and patients. Our primary objective was to evaluate the concordance of practitioner and patient perceptions in terms of explanations regarding consultation, therapy, and patient satisfaction. The subjects were 250 practitioners and their 1250 patients in Fukuoka, Japan. Answers were obtained from 91 acupuncture practitioners (36.40%) and 407 patients (32.56%). Of these, responses from 125 pairs without missing values were used for the analysis.

Abstract

When practitioner–patient communication, as evaluated by the difference between the patients’ and the practitioners’ perceptions with respect to the level of practitioner explanation, was good, patient outcome (ie, satisfaction with therapy, improvement in health) was also good. Factors related to poor practitioner–patient communication included age of the practitioner, the number of practitioners at a clinic, the experience of the practitioner, and the age of the patient. These findings may be useful in improving practitioner–patient communication.

Relevance?

In this study, when the relationship between acupuncture practitioner–patient communication and patient outcome was examined, the most important factor was the level of acupuncture explanation, as perceived by the patient. Reduced patient satisfaction with therapy or less improvement in health was present in those patients who did not feel communication was good.

Study #2

Title: Acupuncture Outcomes, Expectations, Patient–Provider Relationship, and the Placebo Effect: Implications for Health Promotion

Published in: 2002 American Journal of Public Health

Abstract

Objectives. To explore whether treatment outcomes are associated with a patient’s degree of general hopefulness, expectations regarding treatment, attributions of health status, beliefs about mind–body dualism, and patient–provider relationship factors, I studied acupuncture patients’ goal attainment.

Abstract

Methods. Sixty-two acupuncture patients were interviewed before and after acupuncture regarding goal attainment, mind–body beliefs, hopefulness, and attributions of health status. Demographics, acupuncture treatment, and health care usage information was also collected. Acupuncturists provided 3 months of treatment.

Abstract

Results. Patients reported treatment goal attainment from acupuncture. Their perceived outcomes were not associated with previous treatment, patient demographics, or the expected and actual numbers of needle insertion. Successful outcomes were related positively to relationship with providers.

Abstract

Conclusions. Perceived acupuncture outcomes seem not to be related to placebo effects and patient expectations, but rather to client–practitioner relationship factors. Healt2002;92:1662–1667)

Relevance?

A patient’s expectations from acupuncture treatment and relationship with provider are predictors of his or her Goal Attainment Score

Where Did Expectations Come From?

The specifics of this study punctuate the client–practitioner relationship as well as factors such as trust, interpersonal style, rapport, and self-care. Better ways of measuring client–practitioner relationship and rapport are needed.

Communications in General

Recent research on what makes therapy effective suggests that the style of therapy you use is not a major factor. It seems to do more with the quality of the relationship between the client and the therapist and how much the client believes the therapy will help.

What Comprises Communication?

Verbal-tone, pitch, inflection, volume, etc.

Nonverbal-eyes, facial expressions, body language, subtle cues, etc.

Appropriate Communications

Good patient communication involves recognizing and responding to the patient as a whole person.

Patient communication also involves professionalism and good clinic etiquette.

From “Communicating with Patients”

• Get the patient encounter off to a good start

• Monitor your body language

• Practice effective listening skills

• Ask questions that yield information and offer support

• Give answers that will be understood

• Partner with your patient

• Develop cultural competency

• Provide motivational counseling

• Demonstrate empathy and compassion

Lawsuit?

Poor communication can lead to missed diagnoses, patient resentment, noncompliance, and a greater chance of being sued. An often-quoted study published in the Journal of the American Medical Association in 1997 showed that the 2 factors leading to a malpractice suit are bad outcomes and poor provider-patient communication

Why Us?

You are all counselors.

active listening

reflection / clarification

motivational interviewing

being part of change

knowing when it’s more than shen disturbance

Western Psychological Lexicon

Knowing how the rest of the team speaks

Knowing how to protect patient and self

Knowing when to refer

What’s Your Worst Example?

Share your horror stories of medical communications nightmares as a patient, a person witnessing the experience, a practitioner, etc.

What is Psychological Medicine?

“The application of psychology to problems which are presented primarily as somatic disorders.”

Synonymous with “MIND-BODY MEDICINE”

What does this mean in Chinese Medicine?

Is Medicine a Science or an Art?

Is it rational?

Is illness explainable?

Do we need to understand why someone is sick?

How can this be beneficial or deleterious?

Historical and Psychological Background of Medical Models

“The part can never be well unless the whole is well...” PLATO (c. 356 B.C.)

Hippocratic Medicine

Four Bodily Humors = Four Elements of Matter (air, earth, fire, water)

black bile (feces)

yellow bile (urine)

blood

phlegm (mucus)

Humor Imbalance Caused Sickness

This notion formed the basis for therapeutics

Thoughts, feelings, emotions and behaviors interacted with the humors

Nothing to excess = balance and health

Fresh air, sun, sea bathing, rest, moderate exercise were treatments

Galen (greek physician)- 600 years later

Took humoral theory and formed temperament theory

Galen describes four basic personality types

The Four Temperaments

Dominance of Blood= cheerful (optimism), sanguine and ruddy person

Dominance of Black Bile= depression and melancholy in person

Dominance of Yellow Bile= angry (hostility), bitter person

Dominance of Phlegm= apathetic person

Galen and Hippocrates Lasted 2,000 Years

Medieval Times brought demon and evil spirits as explanation for illness - “if you’re sick, it could be your fault” (Robbie, 6, says “Mom, actually it is the wind’s fault. It could be brother wind, so if you getting sick or having problems with yourself, it actually brother wind’s fault. He didn’t mean to.)

Bloodletting, purges, cathartics, exorcism

Ridiculous, or were they on to something?

Enter Edward Bach - Bach Flower Remedies

Why Him? His work was fundamental to the holistic understanding of disease

He wrote that:

disease is a conflict of internal and external forces

When actions are in harmony with basic nature, health/happiness follows

Must restore harmony between actions and basic nature if illness happens (Draw cycle of generation and destruction)

Biopsychosocial Field of Disease

Health outcomes affect and are affected by biological, psychological, and social factors

Dr. George Engel Psychiatrist

Venn Diagram

Biopsychosocial Model

Engel’s Basic Premise

"To provide a basis for understanding the determinants of disease and arriving at rational treatments and patterns of health care, a medical model must also take into account the patient, the social context in which he lives and the complementary system devised by society to deal with the disruptive effects of illness, that is, the physician role and the health care system. This requires a biopsychosocial model."

The Logics of Modern Psychology

Relevance in Healthcare?

The Ghost in the Machine - what is the mind?

Study of Human Behavior and Experience is Psychology

Relevance

Relate to people in therapeutic manner

Not your friends

Not strangers

Freud and Psychoanalysis

Born in 1856

Father of Modern Psychology

Showed us that we aren’t in touch with why we behave as we do

Id, Ego, Superego/Stages of Development

Id - most basic of personalities, completely unconscious, more animal, destructive

Ego - semi-conscious, rational

Superego - conscience, controlled by society “I should or shouldn’t do this”

Oral, anal, phallic, latency, genital

Which Phase?

Oral- 0-18 mos

Anal- 18 mos-3.5 yrs

Phallic- 3.5 yrs - 6 yrs

Latency- 6- puberty

Genital- puberty- adult

John B. WatsonBehavior Theory

Psychology as a natural science of behavior

Used Pavlov’s theories to begin psychological exploration

Believed in “nurture” over “nature” and said he could turn any healthy infant into anything with conditionng

Experiments failed but formed basis for further exploration

B.F. Skinner - Operant Conditioning

Imagine a rat in a cage.

“Skinner box” with bar or pedal on one wall as mechanism to release a food pellet

Rat accidentally presses bar and food pellet falls into the cage!

The operant is the behavior just prior to the reinforcer, which is the food pellet, of course. 

Cognitive Psychology - 1950’s

Cognitive psychology is the branch of psychology that studies mental processes including how people think, perceive, remember and learn

Unlike behaviorism, which focuses only on observable behaviors, cognitive psychology is concerned with internal mental states.

Unlike psychoanalysis, which relies heavily on subjective perceptions, cognitive psychology uses scientific research methods to study mental processes.

Humanistic Psychology-also 1950’s

Abraham Maslow - Hierarchy of Needs

Carl Rogers - Person-centered psychotherapy

Humanistic psychology focused on each individual’s potential and stressed the importance of growth and self-actualization. The fundamental belief of humanistic psychology was that people are innately good, with mental and social problems resulting from deviations from this natural tendency

Maslow’s Hierarchy

Carl Rogers

Empathy - is this the same as sympathy?

Congruence - WYSIWYG

Positive Regard - Even ONE thing you can admire about the person you are sitting with

There are MANY More...

Jung

Gestalt

Existentialism

Positivism

and many more...

Three Approaches to Psychotherapy

Made in 1965 by Dr. Shostrom

Actual Client “GLORIA”

The Three “MASTERS” Worked with Her

Each have very different communication styles

Powerful, Evocative, Disturbing

Carl Rogers

Client-Centered (Person-Centered) Psychotherapy

Fritz Perls

Gestalt Therapy

Albert Ellis

Rational Emotive Behavior Therapy (REBT)

Video Time!

Notice body language, tone, verbal and nonverbal cues

Decide who you most align with theoretically

Discussion will follow next week

Horrifying!

Watch and be HORRIFIED!