Communication as a discipline Claudia W. Allen, PhD POM-1, August 17, 2009

1. Communication as a disciplineClaudia W. Allen, PhDPOM-1, August 17, 2009 Avoiding the “Blah Blah Blah, Ginger” Effect

2. Objectives • You’ll know why good doctor-patient communication is important. • You’ll know what creates good communication. • You’ll be aware of your “at risk” status as a med student and future doctor. • You’ll know what some physicians have done to protect their abilities to be good communicators.

3. Better medical outcomes – you as a healer (helping others) Fewer malpractice suits – you as an earner (practical life) Greater physician satisfaction – you as a happy person (personal development) How might good doctor-patient communication further your goals?

4. Good doctor-patient communication improves medical outcomes: • quicker resolution of chronic headaches • reduced blood sugar values in diabetics • improved blood pressure readings in hypertensive patients • reduced pain in cancer patients • better functional capacity in heart disease and asthma patients. • lower stress hormones in radiology patients • more realistic assumptions in patients making decisions whether or not to engage in life extending therapies

5. Fewer malpractice suits Fewer ERRORS due to better information Fewer CLAIMS regardless of quality of care 8 Avery JK. Lawyers tell what turns some patients litigious. Med Malpractice Rev 1985;2:35–7.

6. Your sense of satisfaction with medicine When a group of physicians was asked what enhances their work satisfaction the most, the most frequently named factor was “relationships with patients.”

9. It starts in med school… High empathy Higher ratings of clinical competence in medical school. Better history-taking and physical exams by fourth-year med students. Empathy in medical students. M Hojat et al. MEDICAL EDUCATION 2002;36:522–527; Collier JA, Willis MS, Robbs RS. Assessment of empathy in a standardized-patient examination. Teaching Learning Med.1998;10:8–11.

10. Good doctor-patient communication What does it look like?

11. Communication 101 Effective communication more information greater impact

12. We call it communication, but it’s really about relationship The mechanics of good communication are valuable as tools to help you create a trusting doctor-patient relationship.

13. the ability to put oneself in another’s shoes. "Identification with, understanding of, and vicarious experience of another person's situation, feelings, and motives.” The American Heritage Stedman's Medical Dictionary Relationships depend on empathy: The bridge between us and “the other.”

14. People don’t care how much you know, until they know how much you care. Lewis Barnett, MD UVA Family Medicine

15. Caring  Buy-in At least half of all patient encounters with a doctor, whether primary care or specialist, REQUIRE behavior change on the part of the patient for successful treatment.

16. Patient: Mr. JonesProblem: increased hypertensionQuestion: Change medication or dosage?Decision: Increase dosage Real Problem: Mr. Jones not taking meds.

17. Listening for emotion Communicating skillfully with a patient requires tuning to the patient's emotions. Halpern, J. What is Clinical Empathy? J Gen Intern Med. 2003 August; 18(8): 670–674.

18. Skill 1 “Listening with both ears” Other ear:emotion in patient’s words, tone, expression, posture • One ear:medical information

19. 1. Hypothesize 3. Feedback 2. Test Skill 2Reflect and listen, Repeat

20. Physicians very often miss important clues about emotion. Patient: No, sir, I’ve never had a heart attack … I worked very hard when I was a young man, a young boy. I was doing a man’s labor and I was always told I had a good strong heart and lungs. But the lungs couldn’t withstand all that cigarettes . . . Physician: Yeah. Patient: Asbestos and pollution and second-hand smoke and all these other things, I guess. Physician: Do you have glaucoma? Morse et al. Missed Opportunities for Interval Empathy in Lung Cancer Communication. Archives of Internal Medicine, 2008; 168 (17): 1853

21. Sometimes we fear that all that emotion will be overwhelming…

22. But…ignoring emotion is inefficient “When opportunities for empathy are missed by physicians, patients tend to offer them again, sometimes repeatedly. This phenomenon can lead to longer, more frustrating interviews, return visits, and "doctor shopping" by patients who feel dismissed or alienated.” Hardee, J. T. A Focus on Patient-Centered Care and Office Practice Management: The Permanente Journal: Fall 2003/Vol. 7, No. 4.

23. So why is this difficult?

24. In medicine as in life, our strength is our weakness • The symptom-focused nature of medicine: the “terminal” in Room 6. • The intense cognitive demands of medicine: little mental space for empathy. • The outcome-oriented focus of medicine: lack of overt reward for empathy skills.

25. Our human limitations • Our own fatigue, hunger, pain. • Our anxiety – can make it hard to slow down and listen. • Our fear of being overwhelmed. “What if I cry, too?” • Sense of failure when we see pain we can’t fix. • Painful awareness of our own vulnerability to illness and mortality. “ Arch Int med

26. Extra demands in medicine “today” Technology Time Regulation

27. These barriers turn out to be very powerful. Empathy scores start out fairly high in med school students. But they drop after first year and then again after third year.

28. "The public tells us they want physicians who are good diagnosticians and also caring people. We start with students who are very caring but have no diagnostic skills and end up with physicians with great diagnostic skills but who don't care.” • (Yikes!) • Richard Frankel, MD, Prof of Medicine and Geriatrics at IU School of Medicine

29. “What would you prefer - a doctor who holds your hand while you die or one who ignores you while you get better?” Greg House, TV-MD

30. It’s great TV drama, but a false choice in real medicine. • In real life, good communication is not separable from quality medicine. • It’s not a tradeoff.

31. What’s the take home? • Learn to listen with both ears – keep one ear out for emotion. • Reflect back what you’re hearing to your patients: find out if you’re right! • 3. Express your empathy – let them know you care.

32. People don’t care how much you know, until they know how much you care. Lewis Barnett, MD Former Chair UVA Family Med

33. So what can you do? • Three strategies predicted higher levels of well being and empathy in residents: • I try to take a positive outlook on things. • I nurture the religious/spiritual aspects of myself. • I incorporate a life philosophy stressing balance in my personal and professional life. J Gen Intern Med 2005 July; 20(7): 559-564.

35. The Nuggets • 1. A good doctor-patient relationship is key to good health outcomes (it helps you do good!) • 2. Good relationships with patients are the main source of satisfaction for satisfied physicians (they make you happy!) • 3. A good doctor-patient relationship reduces errors and the likelihood of being sued whether or not there is an error. (Hence you earn a living!)

36. Good Doctor-Patient Communication 1. Is this something I should care about (invest energy in)? 2. If so, what are its key elements? 3. Have experienced physicians and researchers identified any potential problems that might get in my way?

37. This is med school, right?Why do we care about “communication”? The most dazzling medical expertise can go right down the drain when it’s not communicated in an effective manner in the context of a trusting personal relationship.

38. Good communication is like oxygen. • When there’s plenty of it in the air, we don’t even notice it. But when it’s lacking, all other systems fail – we can’t function. • Without good doctor-patient communication, our medical tools are weakened or become useless.

39. It turns out that the effective transmission of information depends on a strong d-p relationship. • It turns out that the most important component of the strong relationship is empathy. • So empathy is the most powerful component of effective communication.

40. Communication Skill Sets • content skills – what you say • process skills – how you say it • Self-perception skills – awareness of your own feelings and biases

41. Metacommunication • communicating about communicating • “Do you follow me?” • “You seem worried; is that right?” • “I’m not sure I get what you’re saying.” • “You sound really mad at me!” • “Is it ok if I ask you some questions about that?”

42. Metacommunication - your life ring • When content and process don’t match up • When a patient is very upset with you or something about his or her medical care

43. Why invite complaints? As the patient, a metacomment inviting feedback tells you: • that the doctor is really listening; • that the doctor cares enough to take the time to pursue your concerns; • that the doctor is not afraid of potentially unpleasant emotion and so you can be honest, and • that the doctor really cares how you feel.

44. “Listening” includes attending to non-verbal communication Nonverbal attunement led physicians to pause at moments of heightened anxiety, at which times patients disclosed information. If physicians did not do this, patients did not share vulnerable information, despite the physicians asking the patients appropriate and accurate questions. Suchman A, Markakis K, Beckman H, Frankel R. A model of empathic communication in the medical interview. JAMA. 1997;277:678–82.

45. The power of your positive attention A physician simply making contact by observing to the baby’s mother: “I can see she has your eyes,” or “He’s snuggled right into you, isn’t he?” engaged the mothers more than other far more complicated interventions. Brazelton et al.