AACH ENRICH 2011

1. Workshop Track One: Relationship-centered Communication to Improve Clinical Quality and Patients' Experience of CareSession Two: Getting the patient’s and family’s full story AACH ENRICH 2011

2. Objectives for Session 2 • Develop the Patient-centered HPI • Symptom story • Personal context • Emotional context • Identify the skills for data gathering and responding with “NURS”

3. Agenda for Session 2 • Didactic • Demonstration • Learning goals (in small group) • Small group exercises • Debrief/Wrap-up

4. “Recap” Workshop 1 • Build Rapport • Setting the stage (Step 1) • ARTS (ask, respond, tell, seek) • Chief Concern and Agenda Setting (Step 2) • Negotiating priorities

5. 90% 10% Greet Set Agenda Beginning 2 3,4,5 1 (SH, PMH,FH…) Clinician synthesizes… BIOPSYCHOSOCIAL STORY Integrated Patient-Centered and Clinician-Centered Interviewing Middle Physical Exam E d u c a t i o n Pt Centered Pt Centered Pt Centered Pt Centered [CC, HPI ---- -- HPI, PMH, Meds, All., FH, SH, ROS] Beginning: Patient-Centered = Psychosocial and Symptom Data Middle: Clinician-Centered = Symptom and Psychosocial Data Modified from Smith, RC. Patient Centered Interviewing. 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2002.

6. Emotion- • Seeking • Direct •  • 2.Indirect • impact • belief • self-disclosure Emotion- Handling Name Understand Respect Support Core Patient-Centered Skills • Open-Ended • Skills • 1. Nonfocusing • silence • nonverbal • encouragement • neutral utterances •  • 2. Focusing • echoing • requests • summarizing

7. STEP 3:Opening the HPI • Open-ended beginning statement • “You mentioned that your back pain was the most important thing today—tell me more about your back pain.” • If the agenda is multi-pronged…“So, given all that, where would you like to begin?” • “Tell me about your ED visit…”

8. Non-focusing open-ended skills • Attentive listening • Silence • Neutral utterance • uh huh, I see, mmm, okay • head nod, hand gesture • Non-verbal Cues Appropriate eye contact -direct eye contact most of the time Appropriate tone of voice -demonstrates concern and interest Appropriate pace of interview -not too fast or too slow Appropriate posture -generally forward lean -mirror posture of patient

9. Building Relationship • Respond to affect • verbal & nonverbal • Listen attentively and reflectively • Show curiosity about relationship • particularly about perceived barriers • Be alert to nonverbal communication of affect

10. …More Building Relationship Skills • Repeat / reflect aspect (s) of prior statement or conversation • Steer without dominating • Check and summarize

11. Step 4:Continuing the Patient-Centered HPI Symptom Story Description of symptoms (focusing open-ended skills) Personal Context Broader personal/psychosocial context of symptoms(focusing open-ended skills) Emotional Context Develop an emotional focus (emotion-seeking skills) Address the emotion(emotion-handling skills, NURS) Expand the Story Repeat cycle until done

12. Symptom Personal Emotional NURS

13. Physical Symptom Story • Description of the physical symptoms • focusing opened ended skills “…so the shortness of breath began at work with a lot of stress yesterday; say more about the shortness of breath.” -echoing “shortness of breath”

14. Personal Context • Broader personal/psychosocial context of symptoms (use focusing open ended questions)

15. Emotional Story • Develop an emotional focus • Direct • “How does that make you feel?” • “How’s that been for you?” • Indirect • “How has the shortness of breath affected your life?” • “How has the shortness of breath affected things for you at home?”

16. Responding to Emotion • Address the emotion • Name You seem scared. • Understand I can sure understand why you’re frightened. • Respect This has been a tough time for you. I’ve really been impressed by how you’ve been managing at home despite your shortness of breath. • Support I want to work with you to try to get to the bottom of this. • Explore Tell me more.

17. EMOTIONS • Lets name some common emotions that our patients may be experiencing.

18. Step 5:Transition to Middle of the Interview • Brief Summary • Check Accuracy • Summarizing • Indicate that both content and style of inquiry will change • Continue with middle of interview • More focused to allow clinical reasoning • Define the 7 cardinal features of the symptom(s)

19. 90% 10% Greet Set Agenda Beginning 2 3,4,5 1 (SH, PMH,FH…) Clinician synthesizes… BIOPSYCHOSOCIAL STORY Integrated Patient-Centered and Clinician-Centered Interviewing Middle Physical Exam E d u c a t i o n Pt Centered Pt Centered Pt Centered Pt Centered [CC, HPI ---- -- HPI, PMH, Meds, All., FH, SH, ROS] Beginning: Patient-Centered = Psychosocial and Symptom Data Middle: Clinician-Centered = Symptom and Psychosocial Data Modified from Smith, RC. Patient Centered Interviewing. 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2002.

20. Lets Practice these skills • Questions • Practice

21. Respond with PEARLS Partnership Empathy Appreciation or apology Reflections or respect Legitimize Support

22. PEARLS • Build rapport and establish safety • Partnership “Let’s tackle this together.” • Empathy (understanding) “Sounds tough.” • Appreciation or Apology “I am sorry this has been so challenging.” • Respect “I respect your courage.” • Legitimization (validation) “Anyone would be upset by that kind of reaction.” • Support “I’d like to support your decision.”

23. Wrap Up • Developing the patient centered HPI • Opening statements • Non-focusing open ended skills • NURS • PEARLS