Introduction

1. Communication to Enhance Patient ComplianceRuth Livingston, Ph.D.rclivingston@northeaststate.edu423.279.7657

2. Introduction • Family physicians conduct about 180,000 office visits in their careers (Roter & Hall, 2006). • Managed care has made greater demands on healthcare professionals (Meldrum, 2011; Roter & Hall, 2006; Hickson, et al, 2002). • Yet, 80% of malpractice suits are blamed on patients suggesting that they felt “brushed off” or that physicians did not establish rapport with patients (Hickson et al. 2002).

3. Patient Adherence • Financial costs of noncompliance are about $13.35 billion a year in the US and result in 125,000 deaths (Roter & Hall, 2006). • 50 % of patients do not take their medications correctly and up to 90% do not follow procedural treatments. • 10 % of hospital admissions are because of noncompliance. • Researchers suggest that communication is key to improving these statistics.

4. Topics include: • Communication to improve compliance. • Ways to efficiently improve adherence. • Immediacy behaviors that establish trust so patients will listen. • Methods of sharing bad news.

5. Lessons From Aristotle • Rhetorical triangle essential to persuasion

6. Ethos or Credibility = Caring and Competence "If patients like their physicians and trust not only their technical skills but also their commitment to advocate a plan of treatment that really is best suited for the patients, the patients are more likely to comply,” (Roter & Hall, 2006, p. 15).

7. Empathic Listening • Perspective of the disease • Effect on his or her lifestyle • Understanding of why to take the drugs if the patient feels well • Affordability of the drug or treatment • Effect of drugs on social activities • Ability to continue work functions • Emotional factors (Roter & Hall, 2006)

8. Logos – Logical Understanding • Dr. Mark Gebhardt (2011) suggested that physicians should involve the patient in the decision-making process to increase patient awareness and emotional involvement. • 42 % of patients misunderstand the directions for treatment. This is highest among older patients (Martin et al, 2005). • Patients comply more often if they understand the how and why.

9. Pathos - Emotion • Korsch and Harding (1998) posit that patients must believe that the treatment is doable. • If treatment makes them feel bad, they will not follow through so explain the why. • Use positive appeals or explain positive outcomes rather than using fear or scolding. • Consider the patient’s family support, priorities, and motivation.

10. Time Anxiety impedes recall. • Anxiety is reduced if the healthcare professional shows empathy and does not appear rushed. • Patients who are not interrupted will complete their unique stories and explain all of their complaints within the first two minutes of the visit (Meldrum, 2011). • Research suggests that positive listening behaviors improve time efficiency.

11. What behaviors would cause you to think that someone is: • An empathic listener • Caring • Attentive (Halley, 1997) • Relaxed

12. Immediacy Behaviors Behaviors that enhance psychological closeness. • Genuine Smile • Respectfulness • Open posture • Using patient’s name • Proxemics Immediacy improves trust, patient satisfaction, and patient compliance (Martin et al, 2005).

13. Sharing Bad News (Neil, et al, 2002) • Give the news in private without interruptions • Find out what the patient understands about the diagnosis • Find out what the patient wants to know • Warn the patient that bad news is coming and share the information in simple language at a pace the patient can handle • Be honest and caring • Listen to the patient's fears and respond by identifying, acknowledging, and validating his or her reaction • Summarize what has been said and identify sources of support such as support groups • Make an early follow-up appointment

14. Sharing Bad News Positive, effective communication applies by using immediacy, listening empathically, and giving the patient time to express his or her feelings. • Take a few minutes to share your techniques of sharing bad news.

15. Patient self-efficacy • Patients must understand the how and why of the treatment and believe that they can follow through with the treatments. • A non-depressed patient is 3 times more likely to comply than someone who is depressed (DiMatte, et al, 2000). • Self-efficacy is impeded if the side-effects hinder work performance. • Ask about concerns and offer alternatives.

16. Recall 60 % of patients forget doctor recommendations after 10 minutes. • Provide information to the patient and to those with the patient. • Check for understanding. • Provide information in writing. • Encourage patients to set alarms or put information on their calendars.

17. Tips to Enhance Compliance • Enter the room only focused on the patient. • Show immediacy behaviors: smile, sit next to the patient, employ open posture, call patient by name. • Do not interrupt the patient unless it is necessary to ask a question. • Ask about obstacles the patient may have in adhering to treatments. This could be that it interferers with the work day by making him or her sick or sleepy or that it is too expensive. Then discuss alternatives.

18. Tips to Enhance Compliance • Suggest to patients who are technologically adept set alarms on cell phones. • Be friendly, calm, and positive. • Clarify that the patient understands how to follow through with the treatment and why the treatment is important.

19. Conclusion • Compliance is key to patient wellness. • Establish an atmosphere of trust and discuss understanding of treatments. • Consider the variables. Patients differ in understanding, desire to be part of the process, and ability to follow through. • Be aware of the patient’s ability that is based on lifestyle, financial ability, cognitive ability, and attitude.

20. References Bentley, S. (1997). Benchmarking listening behaviors: Is effective listening what the speaker says it is? International Journal of Listening. 11, 1997, pp. 51-69. Bud, B. (2006). Communication Skills that Heal: A Practical Approach to a New Professionalism in Medicine. Seattle: Radcliffe. DiMatteo, M. R., Lepper, H., and Croghan, T. (2000, Jul. 24). American Medical Association. Retrieved from http://stressandimmunity.osu.edu/Img/Pubs/107.pdf DiNicola, M. R. and DiMateo, D. D. (1982). Achieving Patient Compliance: Psychology of the Medical Practitioner's Role. Riverview, MI: Motor City Books. Gebhardt, M. (2011, May). Communication matters. American Academy of Orthopaedic Surgeons Now. Volume 5 (5). Retrieved from http://www.aaos.org/news/aaosnow/may11/managing5.asp Halley, R. (1997). And Then I Was Surprised by What You Said: The importance of love and listening on community. Columbia, MO: Kaia. Hickson, G., Federspiel, C., Pichert, J., Miller, C., Gauld-Jaeger, J., and Bost, P. (2002). Patient Complaints and Malpractice Risk. JAMA. Vol. 287(22): 2951-2957. Korsch, M. and Harding, C. (1998). Intelligent Patient's Guide to the Doctor-Patient Relationship: Learning How to Talk So Your Doctor Will Listen. New York: Oxford University Press.

21. References Livingston, R. (2011). Advanced Public Speaking: Dynamics and Techniques. Xlibris. Martin, L., Summer, L. W., Haskard, K. DiMatteo, M. R. (2005, Sept.) The challenge of patient adherence. Dove Medical Press Limited. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1661624/ Marvel, K. Epstein, R, Flowers, K. and Beckman, H. (1999). Soliciting the Patient's Agenda: Have We Improved? JAMA. Vol. 281(3): 283-287. Meldrum, H. (2011). The Listening Practices of Exemplary Physicians. The International Journal of Listening. Vol. 25 (3): 145 - 160. Neil, J. F., Urban, S., Collier, V., Weiner, J., Polite, R., Davis, E., and Boyer, E. G. (2002, Dec, 17). Journal of General Internal Medicine. Vol. 17(12). 914 - 922. Research Partnership. (n.d.). Maximizing patient adherence by leveraging the patient/physician/pharma relationship. Retrieved from http://www.researchpartnership.com/uploadFiles/files/Freethinking-adherence.pdf Roter, D. and Hall, J. (2006). Doctors Talking with Patients/Patients Talking with Doctors: Improving Communication in Medical Visits, 2nd ed. Westport, CT: Praeger.

22. Contact • I have sped through the processes of communication that is a matrix of complex ideas. • If you would like more information, please e-mail me at rclivingston@northeaststate.edu. • I will gladly send you my notes for this workshop. • Thank you so very much for your attention.