S. McPherson Sept 11, 2003

1. S. McPherson Sept 11, 2003 Back to the basics

2. COMMUNICATION THE GOOD THE BAD THE UGLY

3. Communication… why is it so important? • It is the main avenue by which information is shared between physicians and patients • It has been to shown to directly affect patient satisfaction • It is one of the top expectations of ED patients

4. Patient satisfaction… • Is related to patient expectations and the extent to which these expectations are met • It is a measure of quality care in the ED • Why is this important?

5. Effects of improved satisfaction • Increases compliance with discharge instructions • Decreases utilization of medical services • Decreases malpractice litigation • Increases willingness to return to the ED • Improves job satisfaction of physicians and other ED personnel Acad Emerg Med. 2000;7(6): 695-709 Ann Emerg Med. 2000;35(5);426-434

6. Factors associated with satisfaction Ann Emerg Med. 2000. 35:5;426-34 • On site and telephone questionnaires of 2,899 ED patients • + factors: number of treatments received • - factors: help not received when needed, poor explanation of causes of problem, not told about potential wait times, not told when to resume normal activities, poor explanation of test results, not told when to return to the ED BOTTOM LINE: COMMUNICATION & EDUCATION CRITICAL TO SATISFACTION

7. Factors associated with Satisfaction Ann Emerg Med. 1996.28:6; 657-665 • Telephone interview of 1631 patient 2-4 wk after d/c from ED • Significant factors improving satisfaction • Decreased perceived waiting times • Expressive quality of staff • Information delivery • Respect of privacy • Explanation of care before visit

8. Strategies to improve satisfaction Ann Emerg Med. 1993.22:3;568-572 • 200 patients, half received info about the ED visit at registering at triage • The info group rated satisfaction higher than the control group

9. What Calgary patients want….. • Communication in the waiting room

10. Expectations of Calgarians • Treatment room communication

11. Expectations of Calgarians • Communications about discharge

12. Expectations of Calgarians • Staff communication and behavior

13. Despite our best intentions…. • 45-55% of patient problems and concerns are not elicited by physicians or disclosed by patients CMAJ. 1995.152:9;1423-33 • 40-50% of MD’s instructions are not remembered by patients Soc Sci Med. 1985.19:1;9-18 J Emerg Med. 1997.15:1;1-7

14. What are some barriers to effective communication?? • Differing roles of patient and physician • Power differential • Illness model vs disease model • Threat of evaluation AM J Gstro. 1998.93:5;676-80 S Dakota Med J. 1985;19-23 Md State J. 1983. April;272-78

15. Lack of patient knowledge about medical information • Use of jargon • Numerous studies show that patients don’t know basic terms such as fracture, hypertension, orally, bowel J Fam Prac. 1987.25:2;176-8 Ann Conf Res Med Educ. 1979.18;208-13 • Underestimation or overestimation of patient knowledge base • Leads to limited discussion with patients Med Law. 1986.5;477-88

16. Interview technique • Usually closed style questions • MD dominance of questions • Approx 80-95% of all questions in a MD-patient interaction is MD initiated JAMA.1984;252:7;2441-2446 • Numerous MD interruptions • Avg is 18 seconds into interview BMJ.1991;303:1385-7

17. Disconfirming communication in response to patient • Ignoring presence of person +/- their attempts to communicate • Using a style that prohibits or discourages the participation of the other person • Using behavior to distance from the other person • Using messages that are contradictory or ambiguous • Rejecting behavior Md State Med. 1983.April;272-278

18. Lack of MD/RN empathy • Does the doctor or nurse really care? • Increased compliance if there is a positive emotional attitude of the MD to the patient Soc Sci Med. 1984.19:1;9-18 JAMA 1989.262:9;1228-1230 Ann Intern Med. 1992:116;843-46 • Lack of MD time • Poor training of recognizing and responding to non-verbal cues Med Care. 1980.18:1;376-87 Ann Intern Med. 1989.111:51-57

19. Additional barriers in the ED • First contact with the patient • Noisy environment • Lack of privacy • Frequent interruptions • Stressors on the patient • Pain • Fear • anxiety

20. Additional barriers in the ED • Stressors on the ED MD • High-impact decisions • Stimulus overload • Biorhythm disturbance • Language/cultural barriers • Large number of patients with very unhealthy lifesyles (abuse, violence) • Multiple family members in room

21. Additional barriers in the ED • Large number of patients with diminished rights (altered LOC, psychiatric patient) • Numerous staff involved in care • Variation in patient expectation • Mandatory reporting • Complex social problems that contribute to the presenting concern Acad Emerg Med. 1996.3:11;1065-69 Amb Ped. 2002:2;323-29

22. Tips for improvement Dispelling the myths • Building Rapport takes too much time • Can be established in < 5 min Ann Emerg Med. 1981.10:348-52 • Satisfaction not necessarily dependant on time Pediatrics. 1969.42: 855-71

23. Dispelling the Myths • You must maintain total control of the interview • Fear patient will ramble on and on • If allowed to talk without interruption the longest amount of time is 2 ½ min with avg of 90 sec BMJ. 1991;303:1385-7 • Often first complaint is not the chief complaint J Fam Prac. 1983;16:749-54

24. Dispelling the Myths • The singular goal of the interview is diagnosis • Patients expect to feel cared for • Patients need to tell their story • Patients are seeking reassurance J Emerg Med.1993;11:775-8

25. Simple tips to more effective communication • Make the patient believe that he or she is the most important person during the visit S Med J. 1993:86;27-30 West J Med. 1993:158;268-72 • Sit while interviewing

26. More Tips • Use of Confirming Responses • Look directly at the patient • Appear unhurried • Lean forward to convey interest • Give direct responses to patient communication especially to questions • Discuss concerns raised by patients • Give full attention to the patient during interviews avoid concurrent activities

27. More Confirming responses • Allow patient to speak without interruption • Ask open ended questions especially initially • Tolerate some pauses to allow pt to speak • Ask if you can use the person’s first name and then use it • Nod your head to show you are listening • Smile if appropriate, patients like friendly doctors

28. Still more Conforming Responses • Suggest patient write down questions when you are out of the room • Touch the patient if appropriate • Ask at the end of the interview if patient has any other concerns • Ask patient to repeat back instructions given to ensure recall and understanding

29. More Communication tips • Be an active listener • Acknowledge non-verbal cues • Repeat back to the patient what you hear they have said

30. Use of “I-messages” • Used to communicate physician feeling, opinions or concerns in a non-threatening manner • Less authoritarian • Tend to communicate empathy Md State Med J. 1983:32(4);272-77

31. Effective Communication can be learned • Acad Med. 2001;75:1117-24 • Intensive training of communication skills to residents with baseline, immediate and long duration testing • All testing after program showed improvement • Med Educ. 2001;35:1087-88 • communication training for med students, residents and staff • Results showed improved OSCE results and increased patient satisfaction

32. What about patient recall???? • Implications for compliance • Implications for safety • Implications for satisfaction

33. Strategies to improve recall • Spend more time explaining and ensuring patient understanding • MD’s spend ~1-2 minutes of a 15-20 min interview giving patients information • MD’s think they spend about 9X more time than they actually do JAMA. 1984;252:17;2441-2446

34. Improving Recall • Involve the patient • Ask the patient to repeat instructions • In one study this intervention increased recall from 60% to the 85% mark Med Law. 1986:5;477-88 • Invite questions from patient

35. Think about how information is presented • Better recall of information communicated first • Separate instructions to be remembered from other statements • Categorization of information • Will likely increase recall by 50%

36. Increase the amount of information and repeat statements • Patients remember ~ 50% of what is told to them • If you increase the total amount that is communicated the total amount remembered increases • Attach specific importance to specific info • Specific info recalled 3-4X better than general info

37. Establish rapport and be friendly • Patient recall is improve with a positive or neutral attitude toward the physician • Negative attitudes of either side will decrease recall • Use memory aids • ~ 77% of patients would like written information

38. Effect of time on recall • J Health Soc Behav. 1972;13:311-317 • Patients recall ~ 50% of what is told to them immediately after the office visit • At 1-4 week post interview a similar amount of recall was shown BOTTOM LINE: IF PATIENTS LEAVE KNOWOING SOMETHING THEY WILL LIKELY REMEMBER IT

39. What information should the patient leave the ED with?? • Diagnoses • Results of investigations and why they were done • Expected course of illness • Instructions of what to do if they get worse • Describe appropriate level of activity

40. Information at discharge • Prescribed medications, reason to take them, side effects and schedule • Follow up appointments

41. How good are we at providing this • Few studies look at recall of info post discharge from ED • 1 study found recall was ~ 60% J Emerg Me. 1997;15:1;1-7 • Have no data for patient recall or compliance in Calgary

42. Our proposed QI study • First steps: Baseline data collection to determine our actual rates of information recall in patients discharge from adult ED’s • Target of 100 exit interviews to sample ~ 20% of physicians in the region • Will compare patient recall of information for numerous categories and compare to instructions documented in the ED record. WE’LL KEEP YOU POSTED!!!!!