23 Clinician-patient-family communication

Question 1

What is the evidence for the impact of communication?

Answer 1

• Patients value good communication

- Patients are more likely to litigate when communication is poor

Question 2

What is the impact of good communication on patients and how can it help?

Answer 2

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

Question 3

What are patient expectations of health professionals?

Answer 3

• 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

Question 4

In clinicians who are not sued, what do they do differently?

Answer 4

• 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

Question 5

What did the meta-analysis by Ambady et al., (2002) find?

Answer 5

Changed the frequency of the audiotaped sound that made the content unrecognizable -> which lead to 1/2 being used

Question 6

What did the meta-analysis by Tamblyn et al., (2007) find?

Answer 6

Doctor-patient communication score from the clinical skills (licensing) exam predicted future patient complaints to medical regulatory authorities

Question 7

Explain eliciting and addressing emotional cues

Answer 7

• 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

Question 8

Which emotional cue is one of the most powerful communication tools?

Answer 8

Empathy

Question 9

What is the best way to present risk in health risk communication?

Answer 9

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

Question 10

What is the absolute risk in risk communication?

Answer 10

Your risk of developing the disease over a time period, taking into account risk factors (e.g. high blood pressure, family history of illness)

Question 11

What is a relative risk in risk communication?

Answer 11

• 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)

Question 12

What is an example of treatment effectiveness statement?

Answer 12

“radiotherapy after surgery for XX cancer will halve your risk of cancer coming back”

Question 13

What are the pros of stating treatment effectiveness?

Answer 13

• 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)

Question 14

What are the cons of communicating about treatment side effects?

Answer 14

But the base rate of ovarian cancer is very low => the increase is from 1 in 3,000 to 2 in 3,000

Question 15

Give an example of communicating treatment side effects

Answer 15

“taking hormonal treatment/drug XX will double your risk of developing ovarian cancer”

Question 16

Explain active treatment options and the outcomes according to Moxley et al (2003)

Answer 16

Active treatment options (e.g. surgery, medication) are chosen more often when outcomes described in terms of relative (rather than absolute) risk reductions

Question 17

In risk communication, what does simplification of risk help with?

Answer 17

(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)

Question 18

In risk communication, how are analogies helpful?

Answer 18

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

Question 19

What is the best way to communicate risk?

Answer 19

• 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

Question 20

What are the three decision-making interventions and strategies for patients and their family?

Answer 20

1. Coaching patients to ask questions (ASK)
2. Question-prompt lists (QPL’s)
3. Decision Aids (DA’s)

Question 21

What do communication skills not exhibit?

Answer 21

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

Question 22

Describe coaching patients to ask questions (ASK)

Answer 22

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)

Question 23

What are the 3 questions to ask doctors in ASK?

Answer 23

1. What are my options
2. What are my benefits or harms of those options
3. How likely are the benefits or harms to occur

Question 24

What were the results of the study in ASK?

Answer 24

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

Question 25

Describe Question-prompt lists (QPL)

Answer 25

Provides a list of common questions patients derived from patient and health professional interviews
- Patient/family tick relevant questions and write their own questions

Question 26

What have studies found about QPL’s?

Answer 26

• 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

Question 27

Describe Decision-Aids (DA’s)

Answer 27

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)

Question 28

Is the format important in DA’s?

Answer 28

Format depends on the clinical situation, patient population, and cost restrictions -> more detailed DA’s seem more effective than simple DA’s

Question 29

What are decision-aids effective at improving compared to usual care?

Answer 29

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

Question 30

Describe the effectiveness of communication skills training (CST)

Answer 30

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

Question 31

What were the results of the review of communication skills training?

Answer 31

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.

Question 32

Are CST courses effective?

Answer 32

CST courses appear effective in improving information-gathering skills and support skills but unclear which CST programs are likely to work