Effective communication

1. Effective communication MBBS 1 Friday 13th May 2005 Professor Graham Martin

2. “The greatest problem in communicationis the illusion it has been accomplished”George Bernard Shaw

3. What we need to cover • Evidence about Communication • The spoken word • Emotional voice tone • Body language • Receiving the message • Delivering Bad News • Neurolinguistic programming (NLP)

4. Other People’s Tragedy

5. arrogant power-seeking inflexible defensive dishonest patronising brash egocentric isolated insensitive self-centred uncaring indifferent selfish antisocial amoral devious prejudiced flippant rude aggressive condescending rigid attitudes judgemental Common descriptors of inappropriate medical student behaviours & attitudes

6. Medical Consumerism Doctor to Patient: Do you fully appreciate the risks of this procedure? Patient to Doctor: Sure, you screw up and I’ll sue!

7. 9 February 2001MEDICAL OBSERVER “Patients’ complaints cause years of hurt, study shows”

8. 17 May 2002MEDICAL OBSERVER “GPs left undefended as UMP walks away”

10. Friday 8 December 2000AMAQ MEDIA RELEASE • Alternative models to the adversarial system should be identified. • Aim to speed up resolution and reduce high costs of litigation.

11. The nature of complaints UK Study 70 % of patient complaints • Deserting the patient • Devaluing the patients views • Delivering information poorly • Failing to understand the patients perspective

12. Access to Records Confidentiality Discrimination Delays Refused Treatment Public Health Overservicing Hygiene Types of Issues • Misdiagnosis • Treatment • Negligence • Medication • Conduct • Lack of Care • Cost • Assault

13. Complaint Issues 2000/01 (2,520) • Treatment 1,366 54% • Communication 405 17% • Access 263 10% • Rights 286 11% • Administration 130 5% • Costs 70 3%

14. Communication 2000/01 (405) • Arrogance 91 • Discourtesy 68 • Failure to Consult 76 • Lack of Care/Consideration 68 • Misinformation 55 • Undignified Service 8 • Other 39

16. Who Can Make a Complaint? • User of a health service. • Someone chosen by the user if it would be difficult for them to complain themselves. • Legal Friend on behalf of an assisted citizen. • Minister for Health. • A person the Commissioner accepts in the public interest. eg another health provider

17. The Health Rights Commission …. provides an independent, impartial and collaborative health complaints system designed to improve health care services and promote health rights and responsibilities in Queensland.

18. Reasons People Complain • Regulation I want to ensure this event never happens to anyone else. • Information I want to find out what really happened. • Accountability I want the person brought to account or disciplined. • Compensation I want the money.

19. Complaint Algorithm Poor communication + Patient’s unmet / unrealistic expectation + Adverse event or bad outcome = a writ or complaint

20. POOR RESPONSE

21. POOR RESPONSE “After much consideration and as an act of my good faith, I have decided to allow copies of your medical record to be sent to you. You should be aware that I have no legal obligation to do this.”

22. Referral to Registration Boards 2000/01 (74) • Medical 45 • Pharmacy 5 • Psychologists 2 • Dental 16 • Chiropractors & Osteopath 6

23. Registration Board Action Taken2000/01 • Deregistration 10 • Suspension 10 • Conditions of practice 4 • Censure/Reprimand 4 • Fine 1 • No further action 22

24. HELPFUL RESPONSE “The review of your complaint has provided useful suggestions in terms of process and staff training issues. As such, future patients will benefit from the critical examination of the way in we manage patient concerns”

25. Complaint Resolution Processes • Local Resolution • Assessment • Conciliation • Investigation • Referral to Registration Board • Referral to another entity Eg: Police

26. Personal Injuries Proceedings Act 2002 “Expressions of Regret” Allows an individual to express regret about an incident without being concerned that the expression will be used as an admission of liability or negligence. This statement cannot then be used in court.

27. CONCILIATION A Collaborative approach to resolving health service complaints

28. Conciliation Outcomes • Change in practice or protocol. • Quality assurance changes. • Additional reparative treatment. • Apology. • Full explanation of what went wrong. • Independent assessment of treatment. • Financial settlements - 21% • July 2000 - March 2001 : $1,500,000

29. Compelling evidence base • Good communication leads to better health outcomes • Good communication is professionally rewarding. • Omission of adequate information about diagnosis, prognosis, treatment options leads to patient anxiety and dissatisfaction. • Communication failures as opposed to technical negligence are significant complaints.

30. Sensitive Issues • Child victims - custody issues • Minors seeking contraception, abortion or drug counseling • Elderly patients • Patients with gynaecological problems • Sexually transmitted diseases • HIV patients. Victims of sexual assault. • Mental Health Patients

31. Patients’ difficulties • Understanding, especially in context of anxiety. • Low to moderate anxiety can focus attention. • Significant anxiety or depression leads to an interpretation bias, anxiety about threat, depression about negative events • Intelligence has a weak but consistent relationship with recall • Recall of information is low (General medical outpatients = 54%, oncology = 25%)

32. Consultation structure and content and memory • Patients usually recall the start and very end of the consultation best (primacy and recency effects). • Topics of most relevance and importance to the patient are recalled well (eg medical information). • More statements made by the clinician the less the % of information recalled by patient.

33. Clinician cognitive bias • Clinician estimates of the amount of information provided exceed that recalled by up to 900%. • The order in which patients present problems does not reflect clinical importance • In primary health care 54% of patients complaints and 45% of concerns not elicited. “What concerns you about this problem?” is rarely asked. • Patients tend to seek information re prognosis, diagnosis, causation. Clinicians tend to provide information re treatment and drug therapy.

34. Patient Satisfaction • Empathy, non verbal behaviour, perception of amount of information provided. • Asking patients about their expectations of the consultation increases adherence even if expectations are not met • Recall is enhanced by categorisation, signposting importance, summarising, repetition • Asking patients to repeat information in their own words increases recall by 30%

35. Clinician behaviour • Unless you invite the patient to ask directly, they rarely ask important questions (assume Dr would tell them if important, seems “foolish”, guilt re taking up time). • Usually little attempt to find out what the patient wants • Detachment, inhibits patient self disclosure, warmth and empathy facilitate it. • Non-verbal signs (the way that information is delivered) are significant.

36. In High Concern Situations, People Want to Know That You Care Before They Care What You Know(Vincent Covello) Listening/Caring/Empathy 50% - Assessed in first 9-30 seconds

37. So What do we do? • Be clear, open and as direct as we can • Keep It Simple, Stupid! • Repeat • Draw a diagram • Provide a handout to take home • Provide an Internet Site address if available, and patient has internet access • Summarise • Provide and opportunity for follow-up

38. Rules for Communication • Demonstrate respect for patients - whoever and whatever they are • Your attitudes will be perceived! • Do not be in a hurry • Be available and accessible in a timely manner - particularly in the case of an adverse event or complication.

39. Rules for Communication • Listen actively to a patient’s concerns • Always acknowledge a criticism of treatment or care - and explore in a reasonable manner. • Do not become defensive and short with a patient. • Work even harder the more difficult the patient is

40. Rules for Communication • Be open and honest about adverse events and complications. • Eg: medication errors

41. Rules for Communication • Never criticise another health practitioner’s care. • “I would not have done that”. • “If you had only seen me sooner”. • Disputes in front of patients.

42. “By the way, Doc…..”

43. Case Examples Breast Cancer First Episode Psychosis

44. Voice • Only 7% communication results from words used • 38% verbal behaviour • tone of voice, timbre, tempo, volume • 55% non-verbal • posture, breathing, skin colour, movements Birdwhistle, 1970 • Joseph Stalin Leon Trotsky

45. Body language • Monitor your own body language • Be aware that you can change deliberately if needed • Be careful not to overdo the changes • Practice

46. Exercise Neurolinguistic Programming