23 Clinician-patient-family communication Flashcards
What is the evidence for the impact of communication?
- Patients value good communication
- Patients are more likely to litigate when communication is poor
What is the impact of good communication on patients and how can it help?
Good communication can help patients:
- Remember more and make more informed decisions
- Adhere to medicate better
- Cope better and recover quicker
Good communication reduces stress and burnout in health professionals
What are patient expectations of health professionals?
- Technical expertise e.g. medical knowledge is the baseline
- Accurate information
- Empathy/emotional support - predicts whether someone is a good doctor or not a good doctor
- Access to services - could vary depending on where you live
- Continuity and coordination of care - the continuous care after you leave the hospital and continued visits
In clinicians who are not sued, what do they do differently?
- Longer consultations (only by 3 minutes)
- Explicit agenda for patient
- Asked patients what they would like to discuss.
- Facilitating behaviours (empathy)
- Used humour and active listening
Use a warm tone of voice
What did the meta-analysis by Ambady et al., (2002) find?
Changed the frequency of the audiotaped sound that made the content unrecognizable -> which lead to 1/2 being used
What did the meta-analysis by Tamblyn et al., (2007) find?
Doctor-patient communication score from the clinical skills (licensing) exam predicted future patient complaints to medical regulatory authorities
Explain eliciting and addressing emotional cues
- Eliciting emotional cues -> message from the patient with some reference to emotional (verbal and/or non-verbal) content
- Blocking and facilitating communication behaviours
- Active listening
- Empathy
Which emotional cue is one of the most powerful communication tools?
Empathy
What is the best way to present risk in health risk communication?
Each presentation format has its advantages and limitations
e.g. words, relative risk, absolute risk, pie charts, horizontal bars, 100 person diagram and survival graph
What is the absolute risk in risk communication?
Your risk of developing the disease over a time period, taking into account risk factors (e.g. high blood pressure, family history of illness)
What is a relative risk in risk communication?
- Compares the risk in two different groups of people e.g. smokers vs non-smokers
- Tell you nothing about the actual risk
- The benefit really depends on how common or rare the disease is (i.e. baseline rate/actual/absolute risk)
What is an example of treatment effectiveness statement?
“radiotherapy after surgery for XX cancer will halve your risk of cancer coming back”
What are the pros of stating treatment effectiveness?
- BUT the chance of cancer coming back in this situation is only 2/100, reduced to 1/100 by radiotherapy
- And radiotherapy can have long-term consequences (e.g. chronic diarrhea, infertility)
What are the cons of communicating about treatment side effects?
But the base rate of ovarian cancer is very low => the increase is from 1 in 3,000 to 2 in 3,000
Give an example of communicating treatment side effects
“taking hormonal treatment/drug XX will double your risk of developing ovarian cancer”
Explain active treatment options and the outcomes according to Moxley et al (2003)
Active treatment options (e.g. surgery, medication) are chosen more often when outcomes described in terms of relative (rather than absolute) risk reductions
In risk communication, what does simplification of risk help with?
(What does an (absolute) risk of 3 in 500 mean?)
Most people convert a numerical risk into categorical risk => GIST (i.e. high risk or low risk - it will happen to me, or it won’t)
In risk communication, how are analogies helpful?
The risk of -this- cancer coming is about the same as your risk of:
- Low risk: getting hit by lightning or winning the lottery
- High risk: getting a cold this year
What is the best way to communicate risk?
- Use consistent framing when discussing pros/gains and cons/losses
- Provide base rates of outcomes and use absolute risk comparisons
- Provide information about the consequence of the risk
- Preferred formats are not always the best understood
- 100 dot/person diagrams - greatest accuracy/understanding
- check and re-check understanding of risk
What are the three decision-making interventions and strategies for patients and their family?
- Coaching patients to ask questions (ASK)
- Question-prompt lists (QPL’s)
- Decision Aids (DA’s)
What do communication skills not exhibit?
They do not;
- reflect the personality or natural talent of clinician
- improve with age or professional experience
Effective communication skills can be taught, maintained and improved
Describe coaching patients to ask questions (ASK)
Study in a GP setting: standardised patients
Designed to prompt physicians to provide minimum information but patients need to make an informed decision => activating the patients (who need to be prepared for answers)
What are the 3 questions to ask doctors in ASK?
- What are my options
- What are my benefits or harms of those options
- How likely are the benefits or harms to occur
What were the results of the study in ASK?
It worked -> in consultations where patients asked questions:
- Doctors gave more information, and patients were more likely to share in decision-making
- Majority (87%) asked at least 1 out of 3 Qs
- Almost half (43%) asked all 3 Qs
- Half (49%) recalled all 3 Q’s
Describe Question-prompt lists (QPL)
Provides a list of common questions patients derived from patient and health professional interviews
- Patient/family tick relevant questions and write their own questions
What have studies found about QPL’s?
- Both patient and doctors find this useful -> increases likelihood of asking difficult questions - can be used in later consultations
- More effective with clinicians endorsement -> patient needs to feel that the doctor endorses it
Describe Decision-Aids (DA’s)
Inform (provide evidence about the condition and all options)
Clarify values (explore patient experiences, ask which benefits/harms matter most, facilitate communication)
Support process (guide in steps in deliberation, provide worksheet)
Is the format important in DA’s?
Format depends on the clinical situation, patient population, and cost restrictions -> more detailed DA’s seem more effective than simple DA’s
What are decision-aids effective at improving compared to usual care?
Improves knowledge of screening options for patients, feel more informed, are clearer about their personal values, have more accurate risk perceptions, more actively participate in decision-making and can improve doctor-patient communication
Describe the effectiveness of communication skills training (CST)
Taught to deliver bad news, responding to emotional cues, discuss sexuality with patients, discuss death and dying, discuss alternative medicine, the transition to palliative care
What were the results of the review of communication skills training?
Significantly group differences
- CST group more likely to use open-ended questions and show empathy towards patients + less likely to give facts only
No group differences
- Patient satisfaction and perception of clinician’s communication skills and clinician burnout.
Are CST courses effective?
CST courses appear effective in improving information-gathering skills and support skills but unclear which CST programs are likely to work
