Communication Skills

1. Communication Skills October 23, 2003 Moritz Haager Dr. S. Pandya

2. Objectives • Conflict resolution & negotiation • What are the barriers to communication in the ED? • What strategies & models exist for effectively dealing with conflict? • Dealing with consultants • Giving bad news • Telephone advice

3. Why are we talking about this? • “teaching physician-physician communication skills in EM training programs is in its infancy” • O’Mara. Communication and conflict resolution in emergency medicine. Emerg Med Clin NA 17. 1999 • “Although the ‘Core Content for Emergency Medicine’ includes the topic of interpersonal skills, there remain no published guidelines for teaching these skills within an ED residency..” • Williams et al. Emergency department senior house officers’ consultation difficulties: Implications for training. Ann Emerg Med. 31. 1998

4. The Importance of Communication • “Communication skills are the most important determinant of patient satisfaction with care..” • Brown et al. Effect of clinical communication skills training on patient satisfaction. Ann Intern Med. 131: 822-29. 1999

5. The Importance of Communication • “…absent appropriate communication skills, doctors cannot meet their responsibilities as medical professionals” • “..I do not ever remember having a faculty member sitting with me to talk about my feelings about death and suffering, or attempt to help me reach an understanding about what my patients go through.” • Whitcomb. Communication and professionalism. Patient education and Counseling 41: 137-44. 2000

6. Historical Perspective • In my father’s time, talking with the patient was the biggest part of medicine, for it was almost all there was to do.” • Lewis Thomas • The focus has shifted away from the pt to focusing on disease with our increased ability to accurately Dx & Tx

7. Barriers to Communication • ED probably the worst place • Divergent pt & physician expectations of role of ED & goal of visit • Lack of understanding of triage system • Patient-doctor relationship arises out of necessity rather than choice • Loud & hectic environment • Frequent interruptions & lack of privacy • Balancing department flow & addressing pt needs

8. Barriers to Communication • Telephone consultations • Appearance & pt perceptions • Youthful appearance • Female gender • Lack of formal dress • Social, cultural, language • Pt impairment • EtOH, drugs, disease states

9. Language & Culture • Huge issue in Canada • Virtually all communications research & models based on western principles & values • Unknown as to how these apply to different cultures but easy to accept that the same question put to persons of different backgrounds can have tremendously different meaning

10. Is there any proof this is a problem? • Taylor et al. Complaints from emergency department patients largely result from treatment and communication problems. Emerg Med 14: 43-49. 2002 • Retrospective review of ED complaints • Found that most likely to complaints were from very old, very young, females, and non-english speaking • 33.4 % related to Dx and Tx • 31.6% related to communication • 11.9% related to delay in Tx • 71.5 % resolved through communication alone!!

11. Is there any proof this is a problem? • Williams et al. Emergency department senior house officers’ consultation difficulties: Implications for training. Ann Emerg Med. 31. 1998 • Conducted survey of SHO’s working in ED in England regarding most difficult cases encountered & cause of difficulty • Found that communication problems were a factor in 76% of cases compared to lack of knowledge in 52% • This did not change significantly over 4 months implying no significant improvement with experiences • Authors conclude that formal communication training may be of benefit

12. Communication Problems • Views conflicting with pts 40% • Pts w/ mental or behavioural problems 24% • Intoxicated or aggressive pts 12% • Distressed / anxious pts 7% • Difficult to obtain Hx 10% • Uncooperative / manipulative pt 5% • Language barrier 3% • Pt unable to speak or hear 3% • Children 2% • Conflict of opinion w/ other staff 2% • Williams et al. Emergency department senior house officers’ consultation difficulties: Implications for training. Ann Emerg Med. 31. 1998

13. Elements of Effective Communication • Listening • Speaking • Receiving feedback effectively • Marco and Smith. Conflict resolution in Emergency Medicine. Ann Emerg Med. 40: 347-9. 2002

14. Model of Prinicipled Negotiation • Separate the people from the problem • Focus on interests rather than positions • Invent options for mutual gain • Insist on objective criteria in judging an agreement • Fisher & Ury. Getting to yes. 2nd ed. 1991. Penguin Book, NYC, New York

15. The Challenge • It seems apparent that communication skills are: • Central to practicing medicine • A common problem area in the ED • A potential area for improving pt & physician satisfaction • How do we teach communication? • How do we evaluate whether the curriculum works?

16. Does Specific Training Make a Difference? • Langewitz et al. Improving communication skills – A randomized controlled behaviorally oriented intervention study for residents in internal medicine. Psychosom Med 60: 268-76. 1998. • Randomized 42 residents to intervention (22.5 hrs of communications training) & control groups • Assessment of pt-oriented interview skills in videotaped simulated clinical encounters using Revised Maastricht History and Advice Checklist by blinded observers at 0 & 10 months • Simulated pts also were surveyed for their satisfaction with the clinical encounter using the American Board of Internal Medicine Patient Satisfaction Questionnaire • Found that both groups improved over time, but the intervention group significantly more than the controls • Actors were more likely to recommend physicians from the intervention group to friends or family

17. Assessing Communication Skills • Rosenzweig et al. Assessing emergency medicine resident communication skills using videotaped patient encounters: Gaps in inter-reliability. J Emerg Med 17: 355-61. 1999 • Videotaped 50 pt-resident encounters • Analysis of only 11 using a checklist of 23 desirable & 9 undesirable behaviours by 3 EP’s and 2 medical educators • Only able to achieve moderate-excellent inter-observer reliability on 10 of the 32 items

18. Introductions Introduce self by name Ask or state pt’s name Greet family or friends present Social overture prior to data gathering Rapport Gives comfort Investigates or acknowledges emotional response to illness or ED experience Gives reassurance Talks Pt through physical exam Conflict Management Clearly acknowledges Pt’s viewpoint Attempts to negotiate w/ Pt Information Gathering Allows Pt to tell story Uses open-ended questions Active listening indicators Checks understanding by summarizing information Contracting / Informing Explains immediate plan for further evaluation & Tx Discusses expected time frame Guides expectations of possible outcomes Checks Pt understanding of info given Non-Verbal Communication Position closer to head than feet Emphatic & appropriate physical touch Appropriate eye contact Posture oriented toward pt Key Communication Skills Rosenzweig et al. Assessing emergency medicine resident Communication skills using videotaped patient encounters: Gaps In inter-reliability. J Emerg Med 17: 355-61. 1999

19. Communication Skills Improve w/ Training • Klamen & Williams. The effect of medical education on students’ patients satisfaction ratings. Acad Med 72: 57-61. 1997 • Cohort study of 133 medical students • Compared scores on standardized patient interviews using the American Board of Internal Medicine Patient Satisfaction Questionnaire in 2nd yr with repeat exams in 4th yr • Used medical residents doing same exams as controls • Found that mean scores improved over time • Did not perform calculations to determine statistical significance making it difficult to draw any conclusions

20. Consultation Requests • Go et al. Enhancing medical student consultation request skills in an academic emergency department. J Emerg Med 16: 659-62. 1998 • Simple comparison of taped telephone consultation requests made by medical students briefly trained with sheet outlining structure of request with untrained EM residents • Medical students found to use significantly more likely to use previously identified important criteria of effective consultation

21. Consultation Requests • Medical Student Telephone Consultation Sheet • Hello Dr.______, this is _______ in the ED. I have a pt I would like to present to you • Pause for acknowledgement • Mr_______ is a ___ yo _______ who comes in today complaining of ______ • Gives relevant Hx and data • I think the most likely diagnosis is _____ • This is what I have done for him already _____ • I’d like you to evaluate him for ________ • His condition right now is __________ • Thank you • Total time should be less than one minute • Go et al. Enhancing medical student consultation request skills in an academic emergency department. J Emerg Med 16: 659-62. 1998

22. Do Communication Skills Seminars Improve Pt Satisfaction? • Brown et al. Effect of clinician communication skills training on patient satisfaction. Ann Intern Med 131: 822-29. 1999 • Randomized physicians to taking a 10 hr communication skills seminar at different time points • Assessed pt satisfaction using Art of Medicine Survey scores before and after taking seminar • Found that physicians self-assessment of communication skills was improved, but no statistically significant change in pt satisfaction scores was noted

23. Criticisms • Simulated situations – difficult to know how this impacts upon pt satisfaction in real life • Perhaps the amount of training was not enough, or the time for the training to manifest to short to be detectable

24. Conclusions • Difficult to get a sense from the literature that specific courses aimed at improving communication skills produce tangible benefit • However this may be as much a function of the study designs as well as the limitations of objectifying something that is inherently subjective in nature

25. Bad News • Definition • “situations where there is either a feeling of no hope, a threat to a person’s mental or physical well being, a risk of upsetting an established lifestyle, or where a message is given which conveys to an individual fewer choices in his or her life” • Dosanjh et al. Barriers to breaking bad news among medical & surgical residents. Med Ed 35: 197-205. 2001

26. Advance Directives • A study of audiotaped discussions about advance directives found: • Physicians tended to focus on more clear cut scenarios • E.g. irreversible brain damage vs. severe infection • Pretty clear that most pts do not desire intervention when there is no hope of recovery • More common, uncertain scenarios were inadequately explored • Pts reasons & values underlying their responses were also rarely elicited • Concluded that such advance directive discussions are inadequate to properly guide the physician and family in times of crisis • Tulsky et al. Opening the black box: How do physicians communicate about advance directive. Ann Intern Med 129: 441-9. 1998

27. Death Notification • Unexpected ED deaths are not uncommon (~0.3% of visits) • Represent a major source of stress for EP’s particularily if the deceased was a child • Little effort focused on teaching how to inform relatives of death of a loved one in medical school or residency

28. Death Notification • Buss et al. The preparedness of students to discuss end-of-life issues with patients. Acad Med 73: 418-22. 1998. • Surveyed 226 4th yr medical students about conveying end-of-life issues • 41% felt they were adequately prepared to do discuss this with their pts • 27% had actually had such a discussion with a pt

29. Death Notification in the ED • Tends to be more difficult • Death usually unexpected • No prior relationship w/ pt or family • Previously noted barriers to communication in the ED • Time demands

30. Death Notification Guidelines • Make sure you are speaking to the right family • Take them to a quiet room • Give them a sense that you are not rushing off to see the next pt • Sit down with them • Identify yourself & your role • Communicate with emotion • Convey warmth, caring, & empathy • Appropriate physical touch • Allow them to dictate the pace • Briefly summarize what happened before the pt arrived and while in the ED • Get a sense from them of how they saw the pt’s health • Provide warning of what is to come • Olsen et al. Death in the emergency department. Ann Emerg Med 31: 758-65. 1998 • Ptacek & Eberhardt. Breaking bad news. JAMA. 276: 496-502. 1996

31. Death Notification Guidelines • Avoid “medicalese” : Use simple clear language – tell them the pt “died” rather than euphemisms • Reassure them everything possible was done • This includes reassuring them that they did the right things • Expect & allow for grief response • Expect a range from pathologic grief to anger & resentment • Let them see the body • Body & resus room should be cleaned as much as possible • Prepare family for what they will see • If body terribly disfigured may want to discourage viewing • Ask about tissue donation & autopsy • Encourage them to ask questions • Provide them with follow-up support • Offer clergy or social worker support • Olsen et al. Death in the emergency department. Ann Emerg Med 31: 758-65. 1998 • Ptacek & Eberhardt. Breaking bad news. JAMA. 276: 496-502. 1996

32. Autopsy Request • Why do them? • Explanation of unexpected deaths • Can help improve care in ~50% of cases by clarifying Dx or guiding research • Can help grieving process (i.e. everything was done that could be done) • Discovery of new diseases • Quality assurance • Vital statistics • Validation of diagnostic tests • Dx of genetic or infectious Dz and subsequent Tx of affected contacts • Olsen et al. Death in the emergency department. Ann Emerg Med 31: 758-65. 1998

33. Organ Donation • ED deaths will be limited to ischemia-resistant tissues: • Liver, kidney (if ongoing CPR) • Cornea • Bone • Skin • Tendon & fascia • Cartilage • Veins • Heart valves • Olsen et al. Death in the emergency department. Ann Emerg Med 31: 758-65. 1998

34. Organ Donation • Contra-indications to organ donation • Infectious disease • Cancer (can donate corneas) • Toxic exposures (some exceptions) • Olsen et al. Death in the emergency department. Ann Emerg Med 31: 758-65. 1998

35. Organ Donation • How to ask • Wait until after family has viewed body • Put in terms of letting pt have one final act of goodwill • E.g. Do you think _____ would have wanted to help someone else as his/her final act here by becoming an organ donor?